Thursday, November 18, 2004
07:31 p.m.

the doctor will see you when you're dead; is THAT convenient enough for you?

today's post was made from work, in a fit of fury.
i've never before made a post from work because, although most staff are completely computer illiterate, i'm still paranoid about anyone finding this journal where i occasionally say unkind things about staff and patients.

but today i couldn't restrain myself; i had to vent.

the actual entry was posted in the customers_suck community.
because patients are customers.
and sometimes they should just die.

and here it is:
a patient comes in with his wife and daughter, complaining of angina-like chest pain.
i review his history, and note that the last time he came in with those symptoms, he was send over to the hospital and had his heart stented on a STAT basis to prevent a massive heart attack. furthermore, he didn't have angina symptoms after the stenting, but now they were very severe.

so like the nice and concerned resident i am, i manage to track down his cardiologist and lo and behold - he just happens to be in clinic in the hospital across the parking lot from us. and he'd be happy to see this patient right now!

so i copy and prepare his records for the cardiologist and walk back into the room, puffed up with pride that i was able to get this guy an immediate appointment, and with the same specialist he's seen before. and just a few steps away! without the hassle of going through the ER. how lucky could this bastard get?
i tell him the good news, and what do i get? the daughter makes a sour face, and the wife starts complaining that she'll have to cancel her backpain appointment. the guy asks if the cardiologist can see him at a more convenient time!

fuck. i made them go. but i kinda hope they won't, and that he'll keel over from a massive MI. some people just don't deserve to breathe my air.

ah yes. and esca has come out of blog-hibernation.
i will archive, dear. i will do anything, if only you will spare me a few seconds between coffees.

Sunday, November 14, 2004
10:50 p.m.

fallujah and fark

i've been reading fark.com for entertainment, and came across the discussion on the "ass-kicking" video of the fallujah assault.
of course most of the comments are of the "go america blow shit up!" variety, liberally sprinkled with wishes to enlist after seeing all the cool, cool weaponry, and castigation of those who are against the war as wanting american soldiers dead.
but someone posted the following (i'm assuming the source given to be correct):

"Lao-Tse said...

"Weapons of war are instruments of fear,
and are abhorred by those who follow the Tao.
The leader who follows the natural way
does not abide them.

The warrior king leans to his right,
from whence there comes his generals' advice,
but the peaceful king looks to his left,
where sits his counsellor of peace.
When he looks to his left, it is a time of peace,
and when to the right, a time for sorrow.

Weapons of war are instruments of fear,
and are not favoured by the wise,
who use them only when there is no choice,
for peace and stillness are dear to their hearts,
and victory causes them no rejoicing.

To rejoice in victory is to delight in killing;
to delight in killing is to have no self-being.
The conduct of war is that of a funeral;
when people are killed, it is a time of mourning.
This is why even victorious battle
should be observed without rejoicing."

i think it would be difficult never to rejoice at victory at all. but the sheer joyfulness expressed in that forum and elsewhere whenever the soldiers make something even with the ground, the comparisons to a video game for crying out loud, that just turns my stomach.

Saturday, November 13, 2004
09:29 p.m.

patience wears thin

to be fair, i haven't come across too much stupidity in my new rotation, family medicine.
in my previous rotations, i was somewhat insulated from it. on subspecialty internal, the patients who were admitted at least had something seriously wrong with them. they may have brought it on themselves, as in slowly pickling their liver in alcohol, but they had a valid reason to be in hospital. those who did not were screened out by the poor saps on ER consult duty.
in labour&delivery, it's hard to be stupid. sure, some first-time moms-to-be came in for a check every time their abdomen gave a twinge, but they could be dealt with quickly and send on their way. and i got to practice my cervical exams, which is always a bonus.

but now, in a regular 9-to-5 clinic, i have to deal with all comers. the simple boring stuff like prescription refills and BP checks, the annual health exams, the people fishing for doctor's notes to get them out of whatever unpleasantness they want to avoid, the actual illnesses both acute and chronic, the elderly who i swear are just coming in for a bit of companionship.
none of this bothers me too much. after all, this is par for the course for most family docs. it bores me, especially the chronics who really can't be cured or substantially helped and who just want somebody to listen to them complain. it bores me, and therefore i will never be doing this type of work once i'm ready to practice.
but it doesn't bother me. it's educational, and it's 4 months.

no, it's the idiots who bother me. and while i know that every practice, every specialty has its fair share of idiots, the difference is that these are not my idiots. they belong to the staff, and i can't really snap at them and explain that they are being idiots.
a lady came in with her small child, who was diagnosed with possible (too young to be properly tested at his age) asthma.
the lady was really upset with the "label". she wanted me to tell her it was ok to stop using the puffers her child was given.
do they make the kid stop wheezing? yes? then keep using them, you dolt! hell, even if it's just a really nasty cold, they're helping. why would you even consider stopping before he recovers fully?

i was on call, in night clinic. night clinic is our version of emergency, if it's too trivial for an actual ER but can't wait for a regular appointment. night clinic is fun because we see acute illnesses almost exclusively.
woman comes into night clinic, complaining of medication side effects.
a medication she has been on for the past four weeks, with the same side effects for the entire period.
the side effects were dry mouth.
she had a regular appointment in two days for a medication review.
i didn't check what lie she told the nurse to get into night clinic, as i was too busy trying to figure out if it would be worth it to stab her in the eye with my pencil and give her a real reason to be there, or if i'd get into too much trouble for it. she managed to escape while i was thusly occupied.

these and many other stories highlight some of the stupidity currently facing me.
and i've noticed that after two weeks of it, my tolerance for human stupidity in general has gone down considerably. forced to treat my patients with utmost courtesy, i've began snapping at peoples' remarks in my non-work-related real life as well as online.
oh well, i suppose identifying the problem is the first step in fixing it. i have to come to terms with it because it's me that's being affected, not the idiot patients.
i think a massage might be in order.

Monday, November 8, 2004
05:47 p.m.

post-con, intra-boredom

went with the engaged ones to anime con in our nation's capital. it was...small, and they had glitches, but it was the first time they ran it. and the music videos were good (but not enough, damn it).
and engaged ones won a price for their FMA costumes! yay!
and i spent most of the time desperately reading the battle royale novel fiance bought. but then he told me i could take it home and return it later, so there was no need to try to speed-read it after all.
nor, i suspect, was there any pressing need to stay up until 5am last night to finish it, with a full clinic and a group home visit today.

i remember how excited i used to be at cons a mere few years ago. i had no problem at all sitting in line for literally hours at a time to get into some rooms.
everything was so great. being there was enough.
and this saturday, standing in line for the dealer's room (where in the end i bought nothing), i was struck by how incredibly jaded mature i've become. standing behind us were two younger girls chattering excitedly about getting their hands on anime and posters, while esca and i bitched about the wait, the fact that we could get anything they displayed in any regular comic/manga store without lineups, weird ticket discrepancies, residency...

i blame the cons i attended in korea, really. there are no screening rooms or contests, just endless booths with doujinshi artists selling their wares, and great, elaborately costumed groups of fans. much better costumed than anything i've ever seen in local cons. art and costumes. things you can't get in any random store.
so, in the end, esca is to blame for it all.
also, she drugged me. so there.

snow-swept boredom
for some odd reason, clinic today was extremely boring. every single patient was there for some minor follow-up; blood pressure, med refill, routine Pap, test results.
the most exciting thing i saw all day was a blocked follicle in the lower eyelid. and that's just sad, people.
meantime, my fellow resident had two chest pains and got to go EKG's on them.

it also started snowing today. intense flurries, on and off. time to break out hats and gloves, though it's not yet cold enough for my furry hat-of-animal-cruelty.
driving home yesterday, i was struck by the change in foliage. the fall this year was absolutely gorgeous, or perhaps it's normal for this region. it was my first fall here.
but i loved driving to my obstetrics shifts, stealing glances at the trees. they were so vivid, reds ranging from flaming orange to almost purple, greens still valiantly hanging on, and most beautiful of all, the yellows that seemed lit from within even when the sun wasn't shining (oh, but almost bursting with light when it was).
i contemplated getting out my camera and taking some pics once i saw a friend post hers, but i never got around to it. and then obstetrics ended and i stayed put for a couple of weeks.
yesterday, all that remained on the trees were a few shivery-looking brown leaves, clinging hopelessly against the wind, and some clinging still to the memory of flame. and ringing the highway were the constant evergreens, late overshadowed by the brilliance of fall, stepping up to fill the coming winter with color.

Friday, November 5, 2004
06:46 p.m.

9 to 5...or 6...or 7...

at long last, family practice. or, as the docs here like to point out, "what you'll be doing for the rest of your career".
or not precisely, if i stay in the military, since the population we serve leans heavily towards geriatrics, chronic pain, and people dealing with unemployment and many complex psychosocial issues.
still, it's the closest thing for now, and it's the way a family doctor manages issues that i have to learn.

we were discussing the difference with our primary staff today. in internal med, whenever an admitted patient has some symptom or another, we usually throw a whackload of labwork and diagnostics at them and are stuck having to treat many nonsymptomatic abnormalities that result from this overzealous investigation. quite often these treatments result in many other splendid symptoms that need investigation.

in family practice, we learn the fine art of deciding if investigation is necessary, and when it is necessary. it's part clinical picture and part gut feeling, which we new residents haven't quite developed yet and thusly we're forced to rely on the staff's gut for now.
it's also the art of coming to a mutual agreement by doctor and patient. unlike in a hospital setting, where a patient is basically at the mercy of the health care providers, a family practice patient can decide not to take the pills you prescribe. or he can go to a walk-in clinic to get the pills you didn't prescribe. he can go to the ER and pester them for bloodwork or XR that you didn't deem necessary. it's sometimes hard, getting a patient to understand your reasoning, but it's absolutely necessary.
and it absolutely requires understanding the patient's point of view, their agenda, their expectation of the visit.
and yes, sometimes it's incredibly frustrating. it's only been a week and a lightly scheduled one at that, and i've already had patients who i wanted to just whack upside the head or throw out of the office. dealing with them, dealing with my feelings towards them, is part of my medical education.

the good, the bad, and the ugly
well, not really. but we have favorites, definitely.
in my area there are three residents and three staff. the staff come in one at a time and have very different styles.
our primary staff doesn't book patients for himself, unless they're completely unsuitable as teaching cases or very resistant to residents, and those are few. he's wonderful, obviously loves teaching, is always there when the three of us need to run a patient by him; in fact, that's why he's there. with three residents in his clinic, he probably "sees" as many patients as an average family doc.
the other two have their own clinic while the residents also see patients. one of them has a fairly light schedule and can usually be found to discuss a case.
the other books a very heavy clinic. she can't make the secretary book patients with us less than 30min apart (standard for first-years), but she makes us see her patients inbetween if she's running behind. and, since she's usually with a patient when we need advice, she told us to knock and interrupt her if we need to.
we may need to, but we sure don't want to.
eh, at least we work under the primary staff more than under the other two combined. yay primary staff!
anyways, first week survived, and i'm actually semi-excited about this rotation. there's lots of teaching, primary staff is great, and some of the patients are really interesting and challenging.
only i prefer them to be challenging in the morning, not when they're the last patient of the day. try finding a psychiatrist willing to phone-consult after hours, and you'll really learn the meaning of "challenge".

and now i'm off to visit esca and bfie. anime con tomorrow!

Sunday, October 31, 2004
06:46 p.m.

all good things must come to an end

but what a strange end it was, my last obstetrics shift.

i got in half an hour late, due to whatever they're doing to the poor highway. at some points, they'd closed off one lane and appeared to be working. at other points, they's closed off about 5 m of perfectly good highway for kicks no immediately discernible reason and were nowhere to be found.

in any case, i was too late to scrub in for the section, but that was ok. the hospital has a husband-and-wife team on staff, so whoever is on (it was the wife this time) will usually call the other to assist for surgery. that way they both get paid, and they work well together. far be it for me to interfere.
and perhaps having a student doctor wouldn't have been the best idea in this case, as the mother has had a previous stillbirth. those patients are just extra-nervous.

there was an uneventful vaginal delivery with the doc who likes to teach. he was too busy to try this time, which spared me from mini-lectures about the G6P pathways and other chemistry things i'm perfactly happy not knowing about.
he's also the doc who almost forces the partner to cut the cord, no matter how green they look. it's funny how many men will concentrate on the woman's face as if their lifes depended on it, just to avoid looking down there.

weird...not wonderful
and then came another delivery. induced before her due date, and i was too busy with assessments to really read through her chart. i only took a look at what i needed to know for the delivery, all of which was fairly standard.
i arrive at the delivery, and her doc does most of it. that's fine. the cord has a loose single knot in it, which i've never seen before and which therefore is cool to see. the baby boy is perfectly fine, though clearly very unhappy about this sudden change of environment.
the doc mentioned the knot as the placenta delivered, something i didn't really pay attenting to. we mention things like nuchal cords for documentation purposes, so it seemed pretty standard. i was more interested in looking at the cord.

but the mother's reaction to the birth was off. she started crying, not the "ooohhh, baby" or the "i'm so relieved the PAIN is gone" type of crying, but the clearly upset kind. and she started repeating that there would be no more pregnancies.
this is a common thing for labouring women to say while in labor. once the baby is born they don't really say it.
i couldn't really understand her reaction. she was fine, didn't even need stitches or anything. the baby was fine.
we finished writing orders, and the doc walked me outside and explained.
this was her third pregnancy. her first living baby. the other two were stillborn, their blood supply strangled off by knots in the cord.
such knots can't be detected by ultrasound, and they're supposed to be completely random occurrences. some studies have been done to try to find predictive factors, but other than some unsubstantiated hypotheses like long cords (hers was normal length) they're considered to be freaky chance events.
and she had had three in a row, two fatal. this is why she was induced before dates.
no wonder the poor woman was upset, to hear that in spite of overwhelming odds it had happened again.

midwives are evil, spake the docs
in the afternoon, a couple of the docs started complaining about hospital rules. in particular the one where women doing vbac (vag birth after c-section) had to have access to immediate c-section in case of rupture of the uterus, or if that wasn't available had to be shipped out to a tertiary center.
the hospital apparently defined "immediate" in an unnecessarily anal manner.
but that's what got them going on midwives. in our province, midwives get their insurance paid by the government and are apparently allowed to do vbac at home. given that the hospital demands "immediate access" to an OR in cases of vbac on-site, this seems a litte...weird.
then cowboy!doc quoted a study that quantified the acceptable death rate of infants during childbirth, in populations choosing midwives. note that all midwife-assisted births are low-risk.
the percentage was 1%, which is staggeringly high for low-risk deliveries. this wasn't the death rate for midwife-assisted births, it was the rate the population under study was willing to accept.

now i kind of want to do some lit review on this.
obstetricians often have a pretty dim view of midwives, particularly in our province where fully half of births that start as midwife-assisted end up in hospital under a doctor's care. to them, this seems a waste of taxpayer's money, since both midwife and doc are paid.
but i'd like to know, for example, how the population in the study mentioned above was characterized.

and now i will watch DVD's and eat more icecream. tomorrow i start family med, although it shall be nothing but orientation for the first few days.

Saturday, October 30, 2004
09:25 p.m.

so what is the street value of percocet?

32 hours post-extraction, and i'm surviving on ibuprofen. the guy who took out my teeth must be some kind of evil dental genius. the two percocet i took yesterday only made me slightly nauseous and gave me some side effects of being drunk, without the fun actual alcohol provides.
and yet they can go for over $20 per pill on the street.
the mind, it boggles.

you're an adult, for crying out loud; write like one!
i'm considering seeing the movie saw, so i looked up some reviews.
this is a quote from reviewer wesley morris at the boston globe: "it does manage at times to knead your tummy like dough".
knead your tummy like dough?
knead your tummy like dough?
for fuck's sake, this is a grown man reviewing an R-rated feature, therefore presumably aiming at an adult market.
and he decides his best word choice here is tummy? WTF?

anyways, i have good ice cream waiting for me. i will go lick at it and forget about the tragedy of adults with a 5-year old's vocabulary.

Friday, October 29, 2004
01:22 p.m.

my wisdom is all gone

i have no feeling at all from my lower lip to my chin.
the sides of my mouth are numbed from cheekbone to lower jaw, and when i run my fingers over the area it feels slightly cold. not an unpleasant paresthesia at all.
but i have no feeling at all in or under my lip. and it is extremely hard to speak with the lower lip out of commission and the tongue working at 50%, at best.

no IV for you!
the oral surgeon was uncomfortable with the arrangement for my post-sedation care, where one person would escort me from the clinic and another would take over for the actual watch. apparently the dentist i spoke with yesterday told me she scrapped the whole arrangement, but that's not the way i understood it. anyways, miscommunication. it happens.
in any case, he wouldn't do the extraction under sedation without an escort, and i had none. he offered to do it with local only.
i was fairly anxious because of my prior unhappy experiences with local, but they had some kind of dental course going on so the person doing my extraction would be an experienced oral surgeon who does complicated cases, and was on base to teach the local dentists. my case wasn't complicated at all, and he said he'd use a stronger mix of local (about three different "-caines"). i really didn't want to reschedule, so i went for it.
it took the man 10 minutes for all three teeth. no pain whatsoever except for the freezing needles, which hurt like a bitch even with topical. but needles i can stand.
and he only had to cut up one tooth.

i went over to the family med center to thank them for agreeing to take care of me even though it was no longer necessary, and fended off offers to drive me home (a 10 min walk). i promised to call once i got in. damn, i feel loved. it's like having a parent in the city...some kind of hive parent.

now i shall experiment with drinking fluids. i think i've got the swallowing part worked out.

oh, and esca left me for coffee. she left me for coffee before my really minor surgery!
i shall not forget...

***later***
aaand the time has come for the happy pills.

***40 min later***
wow.
when i turn my head from side to side, there's a bit of a lagtime before my brain catches up with my eyes. i get that when i'm pretty inebriated, too.
i hope they don't make me nauseous. that's the number one listed side effect, but it's also the number one listed side effect for nearly all drugs i've seen.
but if i have to take gravol on top of this, i'll be semi-comatose.
time to go lie down.

Thursday, October 28, 2004
06:00 p.m.

it's jaw-cracking time

tomorrow i'm having all my wisdom teeth removed (i only have 3; i suppose i'm not very wise).
under conscious sedation, because i couldn't convince the army to knock me out.
my old civvie dentist had agreed, following a couple of extremely unpleasant cavity work on my molars, but the army dentist didn't seem to take my story of problems with local anesthetic too seriously. according to her, i should be easy to numb.
she suggested just local.
i vetoed.
the IV sedation is a compromise. it's not really designed for pain control, but it'll probably prevent me from punching out the dentist if the local doesn't work too well.
oh, and i learned i have crappy thin enamel which makes me more prone to cavities, or at least cavities form faster. i hate my enamel.

this is your home
the problem with IV sedation was the escort i'd need for 6 hours after the procedure. i live alone, my friends here are all residents who are not going to get a day off from work to babysit me. on overnight notice, no less.
the army found someone willing to pick me up and deliver me somewhere, but i'd need someone willing to take responsibility after that.
i went to the family med center where i'll be starting on monday, and where the admin for the FM program is located. and i asked the lady who's program assistant if she'd sign the form and let me stay in the library.
she said, "of course. this is your home."
while i was chatting with her, the doctor who's in charge of the program came in, told me that the army had called about me staying there, and informed me that there would be a room with a bed available if i needed it, and that he'd be willing to stay after the center closed if i needed watching for the full 6 hours.
i feel so loved.

i just came back from a spree of buying soft foods. my fridge is now full of ice cream, rice pudding, jello, jogurt, 8L of soymilk in various flavors, applesauce, not to mention the delicious butternut squash soup i got from mom when i visited the last time.
and i have the perfect excuse for frittering the weekend away, watching movies and eating semi-nutritious junkfood.
but then again, i've never needed an excuse before.

Monday, October 25, 2004
01:26 a.m.

i am the bringer of life!

i had the most perfect delivery my last shift.
it was the lady's second child, she had had some demerol but no epidural. she was screaming a bit, and apologizing for it once the contraction had passed, which is just so endearing. i mean, she wasn't swearing, or even shouting very loudly. she wasn't kicking me in the boob, which has happened to me in the past. she was just expressing pain, but no matter how many times the nurse and i and her husband told her it was perfectly ok, she just wouldn't quit apologizing.
she was also in control, and able to follow directions ("don't push!") through the pain. being able to stop pushing is one of the most important ways of avoiding tearing if it can be avoided (and in some cases it can't), because it allows a slow, controlled delivery instead of a tissue-ripping expulsion.
i was able to take my time and gather my wits, to deliver the baby through the nuchal cord instead of clamping and cutting it once the head was out. because of her control, i felt really in control of the arc-like movement of the baby as i delivered it, and i knew, before inspection, that there was no tearing at all.

a great delivery. but what made it perfect, for me, was the obstetrician.
i arrived first, set up, put on my gloves, and started managing the delivery. normally the doc shows up with or right behind me and watches, does some management, maybe gives me pointers (or in the case of crazy church-obsessed doc, starts manipulating my hands and making me feel like a semi-trained monkey, but i'm not bitter or anything).
they tend to let me handle the delivery if it's uncomplicated, but it's pretty obvious that i'm the apprentice and they the big cahuna.
well, that night i was on with cowboy!doc, and when he followed me into the room he stayed out of sight of the patient, letting me be her only doctor. he only became visible to hand me things once the delivery was complete and i was taking the cord blood.

and after the congratulations, for the first time, a new mother thanked me as her doctor.
oh, i got thank-you's before. usually we all do, the doc, the nurses, me. but it's the doc who is turned to first, who's looked at with trust and gratitude that all went well, that baby is lying safely swaddled in the mother's arms.
i'm not sure if i'm explaining myself well. it's not really about glory or gratitude; for one moment in the eyes of this woman, i had brought her baby into this world.
and i'm so happy cowboy!doc let me have that.

money can't buy me love mutsu apples
yesterday we went to our favorite orchard to get apples. my parents like to gather the ones on the ground, which tends to take longer but of gathered carefully can result in apples just as good as the ones directly from the trees at 1/3-1/4 the price.
plus they like the actual gathering.
i was going to help them with their bushels and just buy my own (because "as a doctor you can afford it", teased my mom), but caught gathering fever and collected a half-bushel of various kinds of red apples for myself.
but when i went to buy my bushel of mutsu - oh horror! there were none!
so i determined to pick them myself. and after intensive searching found about 20. i swear, that's all that was left in the whole freaking orchard. i had to settle for my former favorites, golden delicious.
1 and 1/2 bushels for $17. i'm going to get sooo sick of apples before long.

Wednesday, October 20, 2004
02:29 p.m.

junk foods banned from ontario elementary schools

from CTV.ca:
"Ontario's Education Minister Gerard Kennedy will announce Wednesday a specific list of junk foods to be banned from all of Ontario's 4,000 elementary schools, to combat childhood obesity.

CTV's Toronto affiliate CFTO News has obtained the list of banned refreshments and reports that it includes:
*pop
*fruit "drinks"
*sports drinks
*chips
*candy bars
*cookies
*chocolate covered granola bars

Those foods and drinks that will be allowed to stay include: *100 per cent fruit juice
*milk
*pretzels
*popcorn
*muffins with less than 2 grams of saturated fat
*crackers
*granola"

well, yay.
i mean, i'd like to know how the fuck they'll determine which muffins have "less than 2 grams of saturated fat", and i don't think a random cookie here and there is bad, or worse than pretzels and popcorn. and that thin chocolate coating on granola bars isn't the devil either.
sports drinks are also not exactly fattening. still, they're totally unnecessary unless the kid is a real athlete and is actually doing high-end athletics in school; your average child doesn't need that kind of electrolyte replacement.

but something does need to be done, and i'm glad they're doing it. it's disgusting, what kids bring as "lunch" these days. has anyone seen those "yay, you got LAYS!" kid-lunch commercials? potato chips are not lunch, damn you.
i got a sandwich, milk, and a fruit as lunch when i was younger. and when i was older, i followed that same formula, making it myself. in fact, that's usually what i still take with me to work, replacing the milk with water.

wonder if they'll ban that horrid "lunchables" crap.
or chocolate milk. if they banned chocolate-covered granola, they should logically ban chocolate milk. although i hope they won't.

Tuesday, October 19, 2004
07:04 p.m.


and then this hand came out of her vagina and grabbed me!

i've started running again. it's so damned hard to start, but i console myself with the fact that i'm still in better shape than before the last time i started running.
and i was doing good that time. but then came the insane LMCC prep, and then vacation abroad, and then internal med...so many excuses obstacles.
at least my stress-induced weightloss during GI and resp is holding steady.

obstetrics is coming to an end
only two shifts left, sadly. shiftwork is amazing and i shall miss it once i start a regular mon-fri routine.
a couple of shifts ago i was delivering a baby whose arms were twisted in an odd position for delivery, and when i was checking for the nuchal cord a little hand popped out right by where i was holding the head and grabbed my finger. since this has never happened before, the baby's hands usually being folded across chest or abdomen, i freaked slightly and almost dropped the head.
which wouldn't be too bad seeing as baby was still mostly inside mom, but it would've made me look like an idiot before my favorite obstetrician.

my most recent shift was with the weird ("eccentric", according to the nurses) church-obsessed lady obstetrician.
since she's the chief of residents and will get our evals, i was unable to tell her that i do not in fact attend church when she questioned me in-depth about the subject. i told her i go to a local church here, and one where my parents live that i actually attended before i gave up church altogether.
she was very surprised that i didn't know the location of the chapel in the town where the hospital is located (the town i visit for the sole purpose of working a shift and then returning home), and hinted that i should go with her in the morning. a weekday morning.
sorry, lady. i confine my fake church-going to sundays only.
i also listened as she tried to dissuade the son of a friend from marrying in *name* garden instead of in a church, because "god does not live in *name* garden".
good obstetrician though, i'll give her that. annoying as hell to work with because she micro-manages every delivery and tries to physically guide my hands, which i despise, but good nevertheless.

i'm an apple jellybelly
settlers of catan is definitely my favorite boardgame. when the engaged ones visited this weekend we played 14 games over a day and a half, and only stopped because we were tired (and esca didn't want me to catch up, damn her).
i really can't imagine another game i'd want to play that many times almost in a row.
and it's even more fun drunk!
i know how much we played because we kept track with jelly bellies. and although i lost, i could enjoy eating the representations of the engaged ones once they left. mwa-hahaha! i ate your winnings, and now i've become more powerful!

Monday, October 11, 2004
12:03 p.m.

the wiggling toes of PAIN

three deliveries this shift, all boys.
and a boy on ultrasound, costing the mother-to-be a $100 bet.
the last delivery needed forceps to turn the baby, as it was steadfastly refusing to come out. epidural on board, thankfully, because those things are not pleasant.
but even with the epidural, there is a lot of pressure and stretch that the patient feels. i was standing just behind the doc's shoulder, almost leaning against the lady's stirruped foot.
she was a real trouper. no noise out of her whatsoever, even though it's not easy to forcep a baby in the position hers was lying. in fact, i couldn't tell she was in pain in if weren't for...
wiggle wiggle wiggle
every time he applied pressure, her toes, painted deep red and chipped in places, would wiggle. right next to my head. it was cute.

is that a needle in my pants, or am i just happy to see you?
starting in the morning, i experienced several transient episodes of nausea and presyncope. in two instances i had to stop questioning patients and rush to a chair before i dropped to the floor.
the assessment nurse found me after the second episode and accompanied me to my call room to lie down. i was able to talk her out of using a wheelchair, but she wouldn't let me cross the relatively short hallway alone because, in her professional opinion, i "looked shitty."
labor&delivery is virtually awash in gravol, but gravol knocks me out so the doc suggested some IM stemetil. in the ass.
i recovered after that, but 12 hours later my ass was still sore. how do people tolerate those IM meds we prescribe q3h?

and seriously, esca. how is the me-fish? your silence on this matter is...troubling.

Saturday, October 9, 2004
04:54 p.m.

and the lord god said: "let there be light"

OSCE went pretty well. we had 15 min, 3 of which were to be spent on the management plan.
my patient had rectal bleeding, and her psychosocial issue was fear of being undressed for an exam...or for anything at all.
i rushed through the medical issue, not doing a complete history, because i was waiting for the psychosocial issue to be brought up. and i could have taken a full history. i spend a month on GI, after all.

and there was light
the examiner, watching the videotape, questioned me on why i merely skirted the bleeding.
well, i was waiting for the psychosocial issue. i didn't think there'd be time for both.
silence
how did i know there would be a second issue.
everybody knows.
who told me.
i don't even know. everybody knows it, even residents in other programs.
more silence
well, maybe we need to change the scenarios. make some one-issue only.
good idea.

15 minutes is not a realistic timeframe for a brief new-patient medical, social and family history, full history of the presenting illness, discussion the patient's fears about her symptoms in light of her father's death from bowel cancer, exploration of her psychosocial issue and its effects on her personal life, and a management plan. and the evaluation sheet touches on all those points.
i was told that the resident isn't supposed to be able to get to all those issues. and yet, the examiner pointed out that i didn't do a social history, that i skimmed over the symptoms. i did a great job with the fear of undressing, but...
but what? if we're not supposed to be able to do it all, why have it there? why not trim the scenario a bit, throw out the father's death, change the set-up to a known patient who comes in with new symptoms (thus doing away with the whole social/family/past medical history stuff)? it still leaves the medical and psychosocial issues there to explore, but makes everything more manageable.

i'm actually a bit angry after typing this.
this is not graded. it's purely for our benefit, for the sake of practice. and it is good practice; in fact, i wish we had these things more often. but i'm still angry about the set-up, about the unnecessary complexity of a scenario that can't be done in the timeframe given to us.

and i'm glad i was able to enlighten them about the widespread knowledge of how these scenarios are set up. perhaps it will lead to a change. eventually, for the wheels of academia turn slowly.
but i was flabbergasted when i realized they truly didn't know. everybody knows. everybody. honestly, i couldn't say who first told me, the knowledge is just there.
i learned it by osmosis.

Wednesday, October 6, 2004
11:23 p.m.

i could use a pill...

"you can go from week to week,
you can go from year to year,
not a hand placed on your cheek,
not a whisper in your ear.

you can make it through okay,
you can live and laugh and flirt,
it's quite easy in the day,
it's just the nights that always hurt."
- from I Love You, You're Perfect, Now Change

the chibis curled up by my feet today and stayed there for 2 hours without biting. i was absurdly grateful. how sad.

i'm sick and whiny.
the occupational health people at the hospital gave me some kind of vile cough syrup, after efforts to get some from pediatrics failed. was pissed; peds syrups are far less vile.
plus the occ health people looked me with suspicion, as if they thought i was fishing for codeine. hello, idiots? i'm from labour&delivery. if i wanted codeine i wouldn't have needed to come to you.

the night was a total waste. there were a mere two deliveries during the day, no inductions scheduled because tuesdays are c-section days.
which is why i wanted a tuesday.
of course, what i didn't know was that there already was an assistant, an older doc who just comes in to do what is essentially med student-type work and gets paid for it. so i pretty much had nothing to do.
a lady was there to demo a new portable ultrasound that the hospital was considering purchasing, and it was a sucky day for her too. she only got one doc out of six, but she's there for two more days.
she did scan my spleen (normal) and a nurse's gallbladder (sludge).

there was one patient in early labour, so i went to bed expecting to be called sometime during the night. this is what makes getting a good night's sleep so difficult on-call; somehow just expecting to be woken up disturbs rest, even if it doesn't actually stop me from sleeping. i've woken up far more refreshed at home with much less sleep than i did last night with a good 7 hours.
this morning i woke up annoyed, certain that my pager had malfunctioned again and they didn't bother knocking on my door, only to find that the woman didn't deliver at all. meh.
i stayed past my normal quitting time because there was a morning c-section, and i got there before the assistant made it. so he just stood around and did nothing (still got paid though).

tomorrow there's a practice OSCE. in which they'll be taping us.
i don't mind OSCE's, but i hate being taped. i just can't ignore the fact that there's a camera on me. i feel that i have to face it and talk to it.

esca, is the me-fish still alive?

Saturday, September 25, 2004
03:04 p.m.

i have taught you all i know"

thus spake the ob/gyn who likes to teach, asking me to rupture membranes so he won't have to come into the hospital.
of course, i'd already done that under the non-supervision of cowboy!ob/gyn, so i was more than happy to. in fact, i did two this shift.

i also managed to screw the fetal scalp monitor into what was probably the anterior part of the cervix instead of the fetal scalp. it attached somewhere but we got no tracing.
and it hurt the patient when i unscrewed it, so it must've stuck into her flesh instead of the baby's.
oh well. i want to try it again. the concept's simple enough, but she wasn't dilated enough for me to do it comfortably, what with my massive lack of experience and everything.

the screen has "vagina" on it! my virgin eyes!
the hospital recently started blocking some sites, like hotmail. that makes sense, and in fact most hospitals block things like hotmail because there will always be idiots who'll open any attachment in their inbox and crash the entire hospital's system. so i'm not sore about that.
no, i'm sore about the nanny-ware they've apparently installed. teaching!ob/gyn keeps giving me little things to research and i can't find answers because every site that discusses obstetrics appears to have been blocked for "sex content".
this is a hospital. this is not a public library, a school or a daycare centre; only staff have access to these computers. staff who are adults. staff who are health care professionals.
staff who will not experience a mental breakdown if they see the word "vagina".
for crying out loud, we need to sign in every time we access the internet. if there is a problem with people watching porn (i doubt it, the computers aren't exactly in private areas), then it shouldn't be hard to figure out who's doing it. find them, fire them, allow me to read obstetrics journals since my evaluation may depend on it.
this hospital blocked its own obstetrics site.

Thursday, September 23, 2004
12:18 a.m.

of mice and men

there's a tiny mouse living in my apartment.
i've seen it twice, once in the bathroom at night when i was too shocked by the sight to quickly close the door and trap the little sucker, and again yesterday when i saw it make a mad dash towards the locked door of my bedroom when i released the chibis.
it got out by squeezing under the door. that thing's tiny.

today i finally put together my IKEA wardrobe (ah IKEA instructions, all badly drawn with no written explanations, how i loathe thee), and moved the last of my boxes away to make room for it.
of course, i'd found the little sucker's living place. or at least i figure that was it, given the gathering of teensy pellets of mouse-poo. i haven't actually seen the mouse.
if it wasn't so good at hiding i'd just catch and release it. but i can't be bothered hunting it through my apartment, and i won't release the chibis out of the bedroom because then i'd have to deal with their destructive messes.
i think i'll just end up buying some cheap killing trap. i'd feel bad (it is a rather cute mouse, from the two brief glimpses i caught), except i'm not having that thing shitting in random hidden corners of my house.

today was academic day for all first-year residents. they tried to kill us with statistics. i'll probably be skipping the afternoon part tomorrow; there's only so much "relative risk" and "numbers needed to treat" that my brain can handle at one time.
but it's nice to see everyone in one place. doesn't happen often enough.

Thursday, September 16, 2004
01:37 p.m.

asleep at the helm

busy shift, especially during the night.
usually busy means many assessments. but not this time; we had a section, two vaginal births, a pneumonia that somehow managed to circumvent the ER and get onto obstetrics even though her problem had nothing to do with pregnancy, and the drama involved in sending a 34-weeker in labor to a hospital that had an open NICU.
we do have a specialized nursery and can, under some circumstances, take care of those babies. but those circumstances don't include a family doctor on for pediatrics on the day she'd likely deliver.
in a rare moment of free time, just as i was going off to nap, a peds nurse zoomed by with two babies and dumped one on me and one on my staff to watch while she went for a smoke break *sigh*
at least baby slept. and i was jealous, but restrained my mean-spirited impulse to wake it and make it share in my misery.

as well, a post-partum patient almost crashing briefly. she ended up being fine, but for a while there was a real suspicion of a cardiac event or an embolus.
and i was send to her room post-haste because the ob/gyn on call figured i had more recent experience in getting adult blood gases than she did. yay for being useful.

in any case, i was fighting to keep my eyes open during the drive home. the drive's under an hour long and i decided to get on the road rather than crash at the apartment provided by the school for such purposes, but i won't do it again.
i don't think i was in immediate danger of falling asleep at the wheel, but i was very tired and my attention to the road wasn't all that great. in retrospect it was stupid of me to drive.

help me, doctor! i'm urgently infertile!
the ob/gyn on call related the story of a funny consult she received a while back.
it was for an inpatient hospitalized by another service. ok, most services won't go anywhere near the nether regions and will consult those who specialize in it of a problem arises while a patient is in hospital. nothing unusual.
except, of course, the reason for referral. infertility.
that is, of course, an inappropriate referral. infertility is not something anyone needs to be seen for at a hospital. you do not waste a consultant's limited time and patience on something that is so obviously an out-patient issue.
but it also pays to be courteous to colleagues, so she at least took a look at the patient's chart.
this gets us to the reason the patient was hospitalized. acute alcoholic pancreatitis.
yes, that's right. and her chart had a neat little history of her alcohol use. what the fuck are people thinking when they write consult requests like that? i mean, they're doctors. one would hope that they do think.
ob/gyn's reaction: "i'm not in the business of making alcoholics pregnant. consult denied."

"and present it to him like you don't know what's happening"
an hour before shift change, an hour i could've spend sleeping, i'm called to do an assessment.
the first thing i see is the nurses' mildly annoyed faces.
the patient in question was scheduled for an induction yesterday, but didn't get it because it was too busy on the floor. unlike patients in active labour, induction patients can wait so they routinely get send home to await a call-back when the ward isn't as busy.
she came in with exceedingly vague complaints of "feeling unwell", vomiting up her breakfast and cramping, and her description of her pain nowhere resembled labor pains. nor did she have contractions on the monitor, and her cervix was unchanged.
ah, but she felt "unwell", in spite of looking marvellously comfortable.
of course, we realized what was happening. at 0630 there are no patients scheduled for ultrasounds or NST's, it's close to the time when the day ob/gyns take over their own patients from the ob/gyn on call, and there are usually few or no laboring patients.
her wily ob/gyn told her to come in at that time with a BS story full of vague complains, thus assuring that she would be assessed and the case presented to him instead to the ob/gyn on call, who would've promptly send her home. coming in later would be risky because it does get busy.
tellingly, he wasn't interested in her complaints, her vaginal exam, the monitor strip, her general state or anything else when i called him to report my assessment. just ordered the oxytocin. he knew she wasn't unwell or in labor.
and we knew that he knew. i mean, who wakes up at 5am to have toast? bah, i say.

Monday, September 13, 2004
09:41 p.m.

wherein i learn that the uterus resembles a comic-book villain

love the ob/gyn i worked with last shift.

i'm not sure how to characterize him. "cowboy" comes to mind for some reason but is definitely not quite right; nor is anything else i can think of.
he's funny, cocky, and exudes a liking for independence. not just his independence. mine.
as in, go into the patient's room and independently stick a sharpened stick through her cervix.
i'd never ruptured membranes before, but it had been explained to me by others, and i'd seen it done a couple of times. he didn't ask if i knew how to do it, or if i felt comfortable doing it without him in the room. he expected me to go in and do it.
it was very refreshing, after the hand-holding, "stand back and watch me" attitude that many obstetricians in teaching hospitals have.
i did just fine.

he did hand-hold a bit when i had to suture a relatively small laceration after a patient delivered after, i swear, one freaking push.
but after he made sure the hymenal ring was approximated correctly he wandered off. i got to the end and started looking around, not sure how to finish. he came in again and threw a few options at me, most of which i didn't know how to do, so i just picked the one i was familiar with. it ended up looking well enough.

stuffing the thanksgiving uterus turkey
and to top off an already good night - emergency c-section!
i got to assist, which isn't saying much. sections are done by one person, so i didn't do anything more than retract and staple.
and hold the uterus after it was brought out to be closed.
sleep-deprived, it was all i could do not to giggle at it. it looks like a turkey's backside, and the stitches used to close it are exactly like the ones my mom uses to close our holiday bird after stuffing it.
it only lacked a pair of wings on the sides to make it perfect.
i finally told the doc what i thought, but he disagreed.
in his view, the uterus looks like some comic book character called "mucus-face".

during the section, we somehow got to discussing having kids. like most people he assumed i would be having them in the future, but unlike most he didn't patronize me when i told him i wasn't planning on it.
doc: "hmmm, good idea. i decided not to have more after i found out how much work it was."
nurse: "after having three."
doc: "yeah, well, after i figured what was causing it i stopped."

Friday, September 10, 2004
10:19 a.m.

damned obstetricians. they're like...octopi

the difficulty with being a first-year resident with scant knowledge of obstetrics, working shifts with different attendings every night, is that none of them trust you at first.
if they're not occupied in the OR or mowing their lawn, they'll rush into the assessment room, stick their tentacly appendages into every single patient in 5 minutes flat, and leave you with nothing to do.

eventually last night's attending warmed up to me and allowed me to do two deliveries on my own, while he hovered behind me.
it's hard figuring out how they want me to act. one of them constantly quizzes residents and wants us to get involved. one will teach if we look interested, but is more stand-offish. tonight's seems indifferent to residents, but will teach if asked specific questions, and will let me near a patient if i'm pushy enough. there is one who dislikes residents and, having been warned beforehand, i didn't schedule any shifts with her. and i haven't worked with the other two yet.

show that baby who's boss!
yesterday i saw my first forceps delivery. and of course, as with all the more difficult deliveries i've ever seen - no epidural.
the baby just wouldn't come out from behind the symphysis, and the doc eventually attached the vacuum. still no budging.
she let her push some more, but finally had to go for the forceps. and then she pulled.
and pulled.
and pulled.
seriously, i wonder how the baby's head stays attached. the mother was being pulled off the table by the doc, and baby still wouldn't come.
at that point, the husband started crying and had to leave the room.
she ended up with an episiotomy, and even with that had an extension tear.
it always, always amazes me how new mothers seem to forget pain as soon as the baby is given to them. heck, sometimes if they're in too much pain right after the head is delivered the doc will ask them to look down and see the head, and they'll usually stop crying and start babbling in baby-talk. this lady had a partial third-degree tear, and i swear the doc didn't even need local to stitch it up; baby substituted nicely for pain meds.
ah, as for baby, he ended up being nearly 10 lbs and the mother was a relatively tiny woman. no wonder he wouldn't budge.

just reach in and pull it out!
another teen, this time 14 yrs old. man, that's depressing.
also no epidural - the teens rarely get them, i think they fear the spinal needles. they're young and their tissues are stretchy enough that many of they don't even require stitches with semi-uncontrolled deliveries, but they do not tolerate pain well.
this one, in addition to the usual kicking, actually rolled off the bed sideways and tried to get away.
her grandmother was a most...enthusiastic...birthing coach, however. every time mom screamed that she's in pain, gramma would yell happily, "i know, i know, i was too! this is nothing, it's gonna get worse!"

Monday, September 6, 2004
11:13 p.m.

where did all the pregnant women go?

is what i asked the charge nurse at around 2100 yesterday, 13 hours into a 24-hour obstetrics shift and with two assessments (no admissions) behind me.

obstetrics is very, very boring if there are no labouring women on the floor. our call room has a cable-equipped TV, but it's a small, stuffy room and i don't like staying in it too long.
the internet-enabled computers by the nurses' station are fucking slow, and there is a constant audience of bored nurses besides (they, too, have nothing to do if no patients are admitted).
and there's only so long i can read lange's without passing out.

in the morning there were a couple of ER "consults" for missed abortions, but those aren't really what i think of as actual consults. just a brief history of current and previous pregnancies, and a snapshot of medical and family history. the rest is done by the u/s tech, or by the obstetrician if it's a weekend/night.
in fact, one of them was a six-weeker, so with the rather limited equipment available on the weekend we weren't even able to tell if the thing was viable or not. the doc whispered to me that it probably wasn't, but he wasn't sure. she will need to come back in a few days' time for a proper scan.

one delivery early at night, half an hour from assessment to birth. too late for an epidural, but she had obviously taken prenatal classes and dealt with it pretty well. she did scream a bit, of course, but apologized endearingly every time, and once more after it was over. really cute.

and then, in the wee hours of the morning, all hell broke loose.
at 0630, an hour and a half before my shift ended, i was called to assess two patients. another one arrived in the assessment room just as i got there.
i finished with one, got her admitted, called the doc as she seemed very close, and went to the next in line.
just as i was done with that assessment, the doc walked in...and at that moment we were both called for delivery of the first patient i saw.
another one too late for an epidural, but this one didn't take it that well.
although she was still better than the woman on my very first shift, who actually refused an epidural and then tried to squirm off the table when the baby was coming. took three nurses to hold her down, and she still managed to kick my left boob several times (the doc was staying far back on that one).

in any case, the baby finally came. but the placenta did not, and had to be manually extracted.
manually extracted. from the uterus. without epidural on board.
not pretty, trust me.
and while i've never found placentas to be, ummm, aesthetically pleasing, never have i seen such a mess as the extracted one. ewww.

by the time we were done, one of the assessment nurses came to tell us that the patient i didn't get to assess was in active labor, the one i assessed was dilating further and wanted a c-section, and the one who was induced the night before was sick of laboring and wanted a section as well.
but my shift was over, and i got out of there. labor day, heh.

Tuesday, August 31, 2004
08:08 p.m.

endings

i am done with internal medicine.
ok, i am done with internal medicine until march, at which time i will enter the hell of general IM (multipy number of patients, multiply their problems, subtract number of residents, and you get genIM).
but march is far away, and i have uncanny abilities where the ignorance of far-away unpleasant things is concerned.
after all, i managed to ignore my CaRMS application until it was almost too late.

aaahhh! you jinxed us!
since it was not only my last day of resp but also the senior's and the other R1's (the clerks will switch over in another 2 weeks), the senior, W, took us out to lunch. she got another team to cover us for an hour, and figured that with our low number of floor patients we'd be done rounding by 1000, do our discharge summaries, and go eat at 1130.
the stepdown patient decided to crash at 0815.
by the time he was intubated and on his way to the ICU it was just after 1000. we rounded individually and went to eat.
W was paged twice during lunch, about new admissions. this was unprecedented; over the whole month we only had one direct-to-floor admission (most patients go through the ER and are sorted out by the IM resident on consult), and now these two appear during our only out-of-hospital lunch.
seriously, the powers that be hate any kind of well-laid plans.

when cardiologists attack
tuesdays are EKG rounds, where the seniors bring out some interesting EKG's and make one of us go through them. the formidable and scary Dr. M is there as always, but a couple of cardiologists attend on tuesdays only.
probably so they can battle each other.
it's kind of funny. they sit at the extreme opposites of the lecture theatre and try to out-do each other by re-interpreting each other's re-interpretation of the resident's interpretation of the EKG in question. we juniors usually lose them by the first re-interpretation, but i think some seniors manage to follow until the re-re-interpretation.
by the end, though, we're pretty much all glassy-eyed.

the EKG's vary in difficulty, from the arcanely unusual to the dead-simple. today we had one of the former and one of latter, a classic ST-elevation MI.
after the victim resident went through it and figured out which part of the heart was affected, the resident leading the rounds asked if there was anything else one could do.
his hand moved across the table to grasp another transparency.
one cardiologist stirred.
Dr. X: "there is of course no need for a posterior-lead, 15-lead, 47-lead or anything else. all the information you need is right there."
resident, coolly putting on transparency: "you could get a 15-lead while waiting on the cath lab. but don't do it if Dr. X is around."

the miracles of modern medicine
after lunch, i returned to finish my discharge summaries. i was post-call, but it had been an exceptionally quiet night.
so i decided to wait until later in the afternoon and attend the family meeting where our attending would inform the children of my patient that she was practically at death's door.
the lady has some kind of aggressive, probably metastatic malignancy, but she is already far too wasted to be able to tolerate the tests we'd need to do to identify it, much less to survive the treatment should any be available.
every breath is a fight for her, not because she has anything in her actual lungs but because her muscles of respiration are too wasted away to do their work.
she can not swallow her medications. she has ordered us to pull her feeding tube.
her children were not shocked. they could see what was right in front of them; they were resignedly grieved and stoically level-headed.
i made the necessary calls to transfer her to her home city, to be closer to her family. we can do nothing more.
she came to us not for a cure but for a diagnosis, and we can't even give her that much.

Sunday, August 29, 2004
07:21 p.m.

...and that's what it's all about.

second-last cardioresp call: endless calls about chest pains that turn out to be nothing, medication clarifications which the teams should rightfully handle in the morning, being paged for "family meetings" with the anxious and/or self-important family members of off-service patients that i don't know from a hole in the wall (is the patient stable? yes? ok, tell the family to set up a meeting with the cardio resident or staff tomorrow. no, i don't care how far they drove/flew/swam to be here tonight. no, i don't intend to come down and see them. goodnight), code blues in the ICU which we humble floor residents don't get to attend, the inevitable and pointless questions which arise after every single nursing shift-change.

and an acute ischemic leg.

it was a beauty. it was what call should be all about. it was a chance to manage something none of us have actually seen, a chance to frantically look up the fairly scant information on managing vascular emergencies that we have access to, a chance to fiddle with bedside dopplers in a heroic attempt to get a pulse on the non-affected leg of this obese and significantly edematous patient, to practice our focused clinical exam, to theorize about the etiology based on the patient's history.
it was exciting. it was collaborative - the resident covering vascular came with her clerk, and the cardio senior, seeing the general excitement from his perch in the CCU, joined our little group as well.
it was educational, not only our own on-the-go information-gathering, but the tiny (well, he was in a hurry) impromptu teaching session the vascular staff gave us when he arrived to whisk her off our collective hands.
it was over well before midnight.
i'm not kidding. this call rocked.

what the hell IS that smell?
i must've gotten used to it when i was on GI. i don't remember is being like this.
the cardio and resp wards are on the third floor, the GI ward and call rooms a few floors above; call rooms and cardio being on opposite sides of the hospital.
in order to avoid being seen on the resp ward at night after yet another chest pain call (nurses will find something to ask you if you're seen. they always, always will, even if it's non-urgent, even if they never would've actually woken you up for it. the key is not to be seen), i go up to the call room floor and then have to cross the GI ward to get to my room.
when i was on GI, sure, i noticed the smell when a patient puked or otherwise soiled him/herself in my vicinity.
but good grief, the whole ward is permeated by the constant, low-level foul stench of various human secretions. how do people manage to stand this?
how did i?

Thursday, August 26, 2004
06:13 p.m.

so do i have to get married in 1 or 2 years now?

esca's sis got married last saturday.
it was a very nice wedding. the ceremony was catholic and i expected it to be overlong and boring, but the priest actually had a sense of humor and gave a relevant and sometimes funny reading, and it went fairly fast.
when my cousin got married in poland a couple of years ago, the reading was all about the mother of god and how jesus loved her and performed miracles for her and so on and so forth. not much relevance to marriage that i could discern, and sooo freaking long. esca's sis was lucky with her priest.

the reception was beautifully appointed, the food was good, the bar was open, and the old folks made a beeline for the exits as soon as dinner and speeches were over, leaving the young'uns to our blasphemous dancing. it was fun. i caught the bouquet, after the first throw dashed it against the ceiling.
the bride looked beautiful as well, especially when she was running. away. from the dancefloor. which she did a lot.
but her dress was cut in such a way that she looked very pretty when she ran.
esca made her own dress and it came out looking very good. all the charred bits were hidden ^__^

and now i'm back on resp. wah wah wah.

random meeting at the tuck shop
my senior: "i need chocolate for this PICC line i have to cancel."
me: "i need chocolate for the family meeting i'm going to go do."
random R2: "i need chocolate for this consult."
thus reassured that we were not, in fact, consuming junk food for the wrong reasons, we each paid up and went our separate, chocolate-munching ways.

Wednesday, August 18, 2004
05:40 p.m.

"God will never take me alive!"

no idea who to credit the above to, but i found it funny.

so today, after running errands for myself ("oh, they gave you a men's jacket. why did they do that?" "..." "you'll just have to return tomorrow, we'll exchange it for you." "!") and the boy, i found myself contemplating suicide.
or rather, the one time i thought of it.

and it was to be out of spite.
i was about 12 yrs old and in my rebellious, anti-social phase (now, at 26, i can be as anti-social as i want and nobody thinks that's "rebellious". life's not fair to 12-year olds), and i don't remember the exact circumstances.
probably something to do with visitors with age-matched kids coming over, and my mouthing off that i hated whoever those kids were and that i wouldn't let them in my room. in any case, i ended up in the bathroom, cleaning it (not as punishment; it was my routine chore) and staring out onto the concrete 4 floors below me, thinking something malevolently childishly stupid like "mom will be real sorry when she finds out i'm dead."

i don't think i was particularly serious, but i do recall that my suicide-will-punish-her thoughts went on for a while, and that i locked myself in there and cried. mostly out of frustration at having to face other people, i guess.
my brother had a more normal rebelling period, although his went on longer. he yelled and threw things and painted his fingernails black and stayed out all night.
me, i just wanted everyone to leave me the hell alone.

in any case, my cat had jumped out of the window a couple of weeks before that, for reasons far more amorous than teenage rebellion. we found him and his lady curled up together in the parking lot, and didn't even realize at first that his leg was broken.
he didn't complain that much.
but by the time i had my little bathroom fit, he was walking around with a pretty red cast. i decided breaking my leg just wasn't worth whatever it was i imagined leaping from the window would gain me, cleaned the damned washroom, and probably behaved inhospitably to our guests.

i suppose i didn't have an overly dramatic teenhood. about half an hour of thinking about suicide to punish my mom for inviting people over. not bad, considering.

esca still hasn't replied to my frantic email, asking if she's coming over tomorrow or not. i was going to treat her to a spa massage, but if she can't even be bothered to share her plans with me...
i know, i'll kill myself! that'll teach her.

Tuesday, August 17, 2004
02:46 p.m.

one dress?
don't tell me you've forgotten to make my dress?
cause i really doubt sis will be impressed when i show up in jeans and a t-shirt. get thee to a sewing machine, chop-chop!

Monday, August 16, 2004
06:37 p.m.

266 bottles of alcohol on my wall...

i started collecting miniature liquor bottles maybe 6 years ago.
now i'm at the point where i already own all the bottles i could buy at the local liquor stores, not counting the vastly overpriced holiday/theme specials they come out with once in a while.
i have bottles from canada, the US, mexico, cuba, jamaica, germany, france, poland, scotland, finland, korea, china, japan, russia, belgium, denmark, italy, portugal, spain, and probably others i've failed to mention.
i blew nearly my entire non-essentials budget on them while on vacation in the czech republic. the friend i went with was astounded and terrified.
and during my first time in korea (on the recent trip i wisely kept to the airport and other tourist traps) i nearly drove esca crazy by insisting that she ask for them in every place that even looked like it had alcohol.
we eventually found a lady in a cosmetics shop who was willing to bring some miniatures she had at home and sell them to me.
i don't think esca was impressed.

my collection was inspired by a friend of my parents', who has a beautifully appointed bar in his basement, and a huge collection in permanently sealed display cabinets installed along the walls.
i dream of one day amassing a greater collection than he. he travels a lot, but i have friends! friends who travel and are always forced happy to bring me some local beauties.

garage sale of drunken fun!
to continue with the theme: this past saturday my father held a garage sale. i drove down to help set up (and bring some junk i wanted to get rid of).
not much to tell, except that the money from the sale all ended up being spent on liquor. it was a heart-warming family get-together, as mom, dad and i rushed bright-eyed and cash-laden to the local store, figuring out who may buy what so we wouldn't go over our garage-budget.
i got a bottle of bailey's. yay me.

and now to continue my vacation with...
there are annoying little things i need to do, which are hard or impossible to get done while i'm working. arranging paperwork for my promotion, getting my uniform, buying furniture, finding a good place for the pre-wedding haircut.
stupid, annoying, necessary things that i will do during this "vacation", while i'm thinking of how else this precious week could've been used if i'd taken it at some other time.
i think i'll get a massage. there is a spa close to my place, and i've never had a massage. i'm on vacation, damn it. i deserve some fun.

Thursday, August 12, 2004
08:00 p.m.

and the award for the most unfortunate vacation scheduling goes to...

well, it was my scheduling choice.
but...but...i didn't know! how could anyone guess?
my current service, respirology, as of tomorrow will have four active patients.
four active patients.
FOUR! active patients.
this, with a senior, two juniors (well, one with me gone), and as of monday two clerks.
this, with our senior on ER duty over the weekend, acting as gatekeeper, funnelling patients away from our service.
this is what i'm abandoning.

our cap, as that of every other subspecialty, is 18. most are running at 20; GI, my previous rotation, had 25 this morning. all week (we started with 9 on monday) we were waiting for the hammer to fall, for the other services to wake up and start demanding we take more cases.
imaginary referring resident: "you have no patients! take this patient!"
our intrepid senior: "but he has renal failure and liver cirrhosis and angina! WTF!"
imaginary referring resident: "also, a cough! he clearly belongs in resp!"

but it never happened, and we just kept discharging and discharging, until we end up where we are now.
seniors take turns in the ER, and decide which services to consult about incoming patients. seniors, of course, will do anything to keep patients away from their own service, so that they don't have to deal with them once they return to the ward (and to make the attending happy).
so it's a given that we won't get a crazy influx over the weekend. she will, naturally, refer clear resp cases to resp, people with COPD exacerbation or malignant effusions or whatnot. but we don't have to take pneumonias, for example; any service should be able to treat pneumonia.

hot potato!
patients don't realize what goes on behind the scenes when they have to be admitted. unless the case it very clear and there's only a single problem (MI to cardio, COPD to resp, renal failure to nephro) there's a virtual war about admitting the patient to a given service.
nobody wants patients. and if the patient in question happens to be frail, elderly, with multi-organ disease, the various services considered for admission will beg, threaten, and cover behind their caps to avoid getting saddled with them. it's funny and frightening to watch: sometimes it will get as high as the attendings, and sometimes they will yell at each other.
that's why so many patients end up in the dumping ground of the hospital: the general medicine ward.
ER resident: "so, we're giving you this patient because he's short of breath and..."
resp: "that's because he's got congestive heart failure. that's cardio!"
cardio: "oh yeah, well his kidneys are failing. call nephro."
nephro: "for fuck's sake, have you seen his bilirubin level? why wasn't GI consulted for this?"
GI: "that bilirubin is due to cancer. here's the pager for the heme/onc resident. bye."
heme/onc: "my god, we knew about this cancer. it's being managed as well as it can be, and it's got nothing to do with his shortness of breath. can you idiots in the ER do nothing right? here, i'll call resp for you."
IM resident (who sees it coming): *sigh*

eh, yeah.
in any case, i'm off. for 10 days.
and maybe i'll get to see a kinda-traditional korean wedding. esca's sister's getting married. esca had to find little white...collar thingies for her dress when we were in korea.

ah, and we played medical jeopardy this morning at sign-in. the formidable and scary Dr. M, who runs them, divided us into seniors and R1's. seniors won by 200 points - but not really!
one category was spelling, and i answered one of the questions (the name of the BP sounds, and spelled correctly). his correct answer ended in "v"; i'd spelled it with "ff".
after consulting with my fellow residents, and the bible harrison's, i and my senior tracked Dr. M down in his office to claim victory for the juniors - i did so spell it correctly! i may not know any medicine, but damn it, i can spell!

Sunday, August 8, 2004
11:44 p.m.

"go west. like saiyuki"

such were my directions for home, after spending the weekend with the engaged ones.
i meant to leave earlier (oh, like then the sun was still up) since this was my first time driving there and back, but i got sucked into playing settlers of catan.
for at least 5 hours.
straight.

esca has a lieu day tomorrow so she can recover from the alcohol game, but i have to get up ridiculously early and go to work. where they'll give me at least two new patients. whinewhinewhine.

and god, that coffee is still in my system. i won't be able to sleep!

Friday, August 6, 2004
07:00 p.m.

and then there were two

the cardioresp R1's call room has its own bathroom. the medicine subspecialty R1's call room does not.
annoying calls about chest pain notwithstanding, i think this will help me survive the next month.
well, and that one-week's vacation won't hurt either.

actually, respirology is pretty damned good. i currently have 3 patients. 3!
that's unheard-of. but we went into a discharge frenzy early this week, and the service is down to 12 patients. we shall, of course, fill up again. but it was oh so sweet while it lasted *gets all choked up*

last night i took my very first cardioresp call.
this involves carrying 3 pagers - my regular one, the backup one, and the code pager. i was having trouble keeping my pants up, damn it. 3 is a good number for the patients i have to carry, not the freaking pagers.
no codes last night, although i did read up on protocols just in case.

had another death, on cardio. another palliative patient, whose next of kin had to be awakened in the wee hours of the morning and informed (i did not, however, repeat the mistake of calling the family doctor at night).
another cornea donation secured.
another mound of paperwork slogged through.
it is very, very easy if the family's not there, if they sound...well, relieved isn't the right word exactly, but grateful that the patient went in her sleep, peacefully.

it's really just a matter of paperwork. i didn't even know the patient, i never saw her when she was alive. i was merely there to put some things in order, to take my best guess as to the cause of death (that is often a difficult task with elderly pallitive patients), and to sign the forms that would allow her body to be moved on to its next destination on its way to the grave.
except for the conversation with the next of kin, i was yawning through the whole thing.

i dont think i grew jaded to death between my first and second time. it's just that this one was so very easy.

tomorrow (yay free weekend!) i'm off to visit the engaged ones, if esca gets around to supplying me with her new address.
surely she just hasn't gotten around to reading her emails.
surely she wants me to visit.
hmmm...

Thursday, August 5, 2004
02:45 p.m.

rabid feminist idiots who need to be shot

my mother is a counsellor at an abused women's shelter.
such places tend to be run "democratically", non-hierarchically (although there is a supervisor and director, the trend is towards "consensus-building"), and above all, non-confrontationally.
all this sounds good on paper, but in reality it turns too often into a model of abdication of responsibility, and fear of confronting others for their mistakes. not only in shelters, and of course i'm not claiming that it happens in all shelters - although it happens in enough. these places tend to draw overly politically correct, overly touchy employees, overly concerned with never offending their fellow sisters even to the detriment of client care.

on to the story. a woman came into the shelter after being released from a night in jail for assaulting her husband. he allegedly tried to choke her, and she defended herself, scratching him. when police arrived, he was the only one with marks of violence on him, and she the one who was arrested.
fair? no, of course not, but that's merely background.
one of the conditions of her release was that she could see her child only in the presence of a third party. the husband was given temporary custody.

the lady is a recent immigrant, and not very familiar with our country's laws. she originally went to a homeless shelter, but was transferred to my mom's shelter, so she could get better services.
so what did the two rabid feminist idiots do? why, they convinced her that she "had her rights", that she should take the child while her husband was out of the house and bring it to the shelter, in violation of the court order.
and she, not knowing any better and listening to the "experts", did just that.

soon enough police in three cruisers arrived at the shelter, ripped the crying child from her arms, and arrested her for kidnapping. severe, yes, but that's the law and none of it would have happened it she wasn't told to break the law.
she is now jailed for a month, and has a snowball's chance in hell of regaining custody. some shelter workers came to her arraignment, when the judge asked if she had someone to provide surety for her. she looked hopefully and expectantly at the workers, who of course could do nothing at that point.
i wonder why they even bothered to go. to gawk at their handiwork? to give her false hope of rescue?

in short order, the ass-covering-up began.
one of the two was initially apologetic, accepting that it was her fault. she was quickly talked out of it, a "teambuilding" meeting was called, and it was made clear that the most important thing for "the team" was to lay no blame where it clearly belonged.
at the meeting someone raised the point that perhaps a case review could at least be undertaken, to provide some structure and guidance so idiot employees would at least have to consult with someone higher up before they gave idiot advice.
no, the executive director said, they have decided to institute a policy of not opening the door to police unless they had a warrant.
what the fuck will that accomplish? they HAD a warrant!

and in a beautiful moment of sisterhood, the director also said, "don't worry about the woman, she is taken care of."
she is taken care of.

i feel the urgent need to stab something.

Wednesday, August 4, 2004
08:59 p.m.

wait til she can stand up, and turf her before she collapses

this month i'm on respirology; just enough time to get used to one service, and then the switch.
i don't mind resp, but it's slower than GI, more elderly long-term patients who decondition in hospital and must be somehow returned to a semblance of strength. enough to be able to leave. as my senior told me, "we're not running a hotel here".
and yes, quite true. there is a shortage of beds. all internal medicine services are running over their caps. this is not a rehab facility.

but there is also a shortage of chronic care beds. wait times for nursing homes are announced in terms of months. shorter-term rehab facilities are overbooked. community care can't keep up with demand and cuts services: is a once-a-week visit to help with a bath and groceries enough?
onto this picture superimpose a frail, elderly patient with a progressive chronic disease, helped up to the washroom mostly because nurses want to avoid falls, seen by physio for perhaps 30 min each day. she lies in her bed or sits in her cushioned chair most of the day because that's easiest, for her and for the staff. her meals are brought on a tray, and the tray is taken away again. her meds are given like clockwork, without her needing to worry about it. her family visits her, sees her dwarfed by the cushions, weak from whatever event brought her into hospital.
how can she possibly be discharged? just look at her!
and yet she will be. and soon. because we can't do anything more for her medically, and her recuperation (should she ever fully recover) will take weeks if not months. and these are weeks she cannot stay here, taking up an acute-care bed.

today i had another of those conversations with my patient. empathetic, diplomatic, but firm. we are having a family meeting tomorrow. we are working on a discharge plan.
we want you to leave.
deja vu, and not a pleasant one, since the day after my last similar conversation with a patient in a similar condition she fell and lacerated her head. she's still there on the GI floor, with physio frantically working to make her ambulate independently; to make her barely well enough to finally leave.

and the paperwork, the supportive services, the calls to community care and nursing homes, all that eating into the days i should be learning medicine.
you will need to know this as a family doctor, they tell me, assuming that a family resident doesn't have as much right to bitch about it as certain other subspecialty residents stuck in internal along with me do.
but no. no, i intend to go career military, and that is the point. i will not have to deal with this. i don't like dealing with it, and i don't intend to burden my future with it. it holds no interest whatsoever, and the sheer amount of bureaucratic hoops i must jump through sucks away any empathy i have for these patients. they take up too much of my learning time.
i want them to leave.

on resp, my senior is female. she's very nice and helpful, understands that i don't yet know about about service-specific things like ordering home oxygen.
she's more reserved that my GI senior, but certainly also has a sense of humor.
but again, i feel that i get along better with men. there's just this sense of easy cameraderie, a sense i feel even around male staff, a sense i don't really have around women. even women i like and admire, and would like to model myself on. even though my closest friends are all female.
it may very well be why the military attracts me so strongly.

Sunday, August 1, 2004
02:13 p.m.

my first death

tonight, for the first time, i declared a patient.
she was from a service i was cross-covering so she wasn't technically mine. she was palliative, so it wasn't a shock. but still, my first.

it was hard dealing with the family, even though i recognize that this was probably as easy as it gets. they were prepared, she was comfortable. they were teary-eyed but stoic, and they asked sensible questions which i was able to answer.
i wish i had known them and the patient. as it was, i came on, skimmed the chart and went in there, a total stranger to the deceased and the family. how much better for the family it must be to see a familiar face at a time like this.
i muddled through it as best as i could, and i think i did well enough. i felt like an impostor actually, until i broached tissue donation, which was accepted. then i felt i had a role, explaining procedures, seeing that this may do a tiny part towards helping them deal with the death.

not surprisingly, in our bureaucratic society a death engenders a slew of paperwork; donation procedures doubly so. paperwork i'd never done before.

actually, i was so frazzled by the end of it that i forgot the rule of not calling the family doc about an expected death until the next day, and made the call in the wee hours of the morning instead. it was on the sheet - notify family doc. i was on sheet-following autopilot by then. but honestly i didn't even think i was calling him, i thought i was calling his answering service.
yes, so i got yelled at for interrupting his "first good night's sleep in so-and-so many days." i could empathize, being sleep-deprived myself. i apologized abjectly and explained that it was my first death, so he stopped yelling and merely reminded me harshly never to do it again.
sigh.

not a good call night, in other words. dealing with death isn't up there with "good" learning experiences, but at least it's a necessary one.
but being yelled at by the end of it, after dealing with the pronouncement and its attendant paperwork for a good 3 hrs on about an hour of sleep in the last 24, just totally did me in.
at least i got to do my first central line, albeit on a dead patient (donor people needed blood samples).

and tomorrow i'm on again, with another oncology patient hanging on by a thread. i feel horrible about even thinking it, but i'm hoping he goes before i start my call.

Friday, July 30, 2004
06:31 p.m.

internal medicine's most dreaded phrase

interesting case.

in the parlance of internal medicine, this translates to something like "WTF is going on with this patient, and why is it getting worse?"
i have one interesting case right now. interesting and complicated (another dreaded phrase, usually meaning "consult other services on this...no, i don't know which ones"), now followed by us, ID, surgery, interventional radiology, and supportive services like nutrition. we all have pieces of the puzzle, but try as we might we just can't fit them together.
we have begun theorizing that perhaps it's pieces of several different puzzles that we're holding, and jamming them together to see the picture just isn't working.
the most "interesting" aspect of the case appears to be resolving on its own. we spent i don't know how much money on fancy tests and imaging to find a cause for it, but have been unsuccessful. now it may go away, and we can only hope it won't recur.
the rest, we'll soon leave to the surgeons. our part is done, or possibly too interesting to continue. we don't know.

for surgeons, interesting and challenging is not a mortal blow. it tends to refer to the technical difficulties of the procedure, rather than to the general cluelessness of what's ailing the patient.

i've had another interesting case, since discharged. we followed her odd bloodwork right to the top, to that most unpleasant diagnostic procedure, the bone marrow biopsy. we involved hematology and oncology, and ID just to cover our bases.
and nothing. or perhaps many many little things, slowly getting better on their own, too small in and of themselves to be found as sole or significant contributors.
she got better. she went home. i laboured over the discharge summary, to justify so many tests for so little gain.

"Medicine is the art of entertaining the patient, as the body heals itself."
-Voltaire

other medical terms, just for fun:
functional - we have not found a cause. we blame your body.
psychogenic - we have not found a cause. we blame your mind.
iatrogenic - we have found the cause. you're looking at it.
idiopathic - not only have we not found a cause, we've given up looking and tried to make sure no one ever looks again.

Wednesday, July 28, 2004
03:10 p.m.

huh. well, of course you don't cry over patients. after all, they're not chain-smoking anime bishies or reindeers.
btw, did you get my email? the one about you still paying for electricity over here?

the proverbial straw

yesterday i was post-call, and it should've been a good day. i got more sleep than on my last call, enough to at least run some necessary chores before collapsing.
i was ready to take on the world (or at least tackle the buying of a bed).
but first, i needed to check email. so i turn on my wonderful, recently diagnostically cleared computer, and...
nothing.
and more nothing.
and still nothing.
damn thing couldn't find its boot record, or whatever. i found its boot record (well, its backup disc) and re-installed my OS, knowing full well that all i had would be lost. but since the last (me-induced) crash there was really nothing vital i needed to preserve.
it seemed to work.
only...it didn't. it refused to recognize my second hard drive, refused to let me re-install sympatico, plain refused to work.
so i had to take it to the computer people, with whom i was already furious for giving the thing a clean bill of health not two weeks ago. if it is a motherboard problem i'm not paying the fuckers, since that's exactly what i told them to rule out in the first place. which they did.

by then i wasn't feeling up to bed-hunting. it's the little things that can turn my mood sour like that, especially when i have free time. it's a feeling of failure, and a reluctance to start anything new until whatever caused it has resolved. it paralyzes me.
not at work. today, in the hospital, i feel just fine. i'm doing my work, cursing family doctors' offices which all apparently close on wednesdays, mentally wishing vengeance in the form of crampy diarrhea on whichever wily resident admitted a heme/onc patient to our service (attending: "so...why is he under GI?"; yours truly: "ummm, he has...gallbladder...problems"; attending: "yes. the problems are cancer. why is he under GI?"), generally going about my business with my usual attitude of hatred for hospital paperwork and endless bureaucracy.
it's when i have free time and some plan doesn't work, or some unforeseen annoyance (god i hate computers) comes up, that i freeze. it's when i can't immediately fix it myself that it ruins whatever remains of the day.
it's just this feeling of...something unfinished, hanging over me. it's supremely annoying.

Sunday, July 25, 2004
10:34 p.m.

on death and dying

i have not been personally affected by death since the time my baby sister died of an anaphylactic reaction to penicillin.
of course, i didn't know why she had died, not then. for years, i had a vague idea that it had to do with "bad medicine", but no specifics.
nor did i ask, even once i was old enough to understand the cause. i suppose by then i wasn't overly interested.

she was a baby, pre-crawling stage, pre-personality; or at least, she had no personality that i, as a young child myself, could discern. our interactions with her were limited to rocking her and watching the stroller in the garden while mom was cooking or cleaning.

we were coming home from school when we saw our grandfather by the big trashcans in the front yard. i can't remember if he was crying at that time; i don't think he was. i remember very clearly what he said: "a horrible thing happened in the house. *my sister* has died."
i remember i burst into tears, suddenly and explosively. i believe my brother did as well. we raced up the stairs to our home, and most likely threw ourselves at mom. maybe at dad.
i don't remember anything after that.

i think we might have been taken by friends. we probably didn't stay in the house; my mother would've been in no shape to look after us. i remember not understanding, at some later point, why there was no special dedication for her at mass, and being told that at her age she didn't need one, she was an angel already.
i have many vivid memories of my childhood before her. it's not that i was too young to remember. but i don't.
she was too young, really, to matter. too young to be a play partner, too young even to get into trouble. to me, at that age, she was a non-entity, and truthfully i cannot even remember her face.

when we visited her grave the last time we were in poland, i tried to remember, and i tried to cry for her. but i couldn't. instead, i cried for my mother who stood beside me, swept up in grief.
and while i cried for her, a little part of me called me disloyal, that i wasn't crying for my baby sister.

that is my only experience with sudden, close death. my grandfather died eight years ago, while i was on an army course. my parents called to tell me. i didn't cry; i went to my room and reminisced about him, and then continued studying for next day's exam.
he was over ninety, fully competent mentally and physically until about a week before his death, and he died an expected death at home with his wife and priest in attendance. we should all be so lucky.

my brother did experience death up close, at an age when it could, and did, scar him.
he went boating with a friend of the family and his child, at a time of year when it was fairly cold. the boat somehow capsized and all three ended up in the frigid water; only the small child was wearing a lifejacket.
the family friend was unconscious, and sinking. my brother, studying to be a lifeguard (i think he was at the bronze medallion level at the time), tried to help. but he didn't have enough skill yet, the man was too large, the water too cold, and the clothes and shoes too hampering. my brother saw him sink, and barely made it to shore himself.
he quit lifeguard training immediately.
to the best of my knowledge, he never again swam in open water.

so i count myself lucky for my lack of experience. and yet i wonder if i'm missing something, not the experience but the proper reaction to death.
now that i'm a doctor, i have patients who die. my patients. and yet i remain fairly unaffected emotionally. not cold, exactly. i empathize with the family's pain, the patients' fear if they're not too far gone to feel it. i don't want them to die, or alternately i want them to go quickly and peacefully if go they must.
but i don't think about it afterwards. i don't go home and cry. i don't feel the need to "talk about it" with a senior.

i'm sure i'm not the only one. i've never run a code, but i've spoken to those who have. usually, the patient dies, and we're prepared for that ahead of time. we know the statistics.
to my knowledge, nobody breaks down in tears, bangs on the patient's chest begging them to live, keeps going with the resuscitation after being told to stop. this isn't ER.
when asked about the results, the doctor in question will invariably shrug and state the the patient died. matter-of-fact, without pausing for a sad shake of the head; that's reserved for families of the deceased.

i kind of wonder if it's different in pediatrics. somehow, i imagine it is.
i wonder if i'll feel the difference.

Wednesday, July 21, 2004
07:48 p.m.

i have achieved the internet, at last!

yes. nothing much more to report. i have internet at home, and shall spend the evening on it instead of hard at my studies. patients, and possibly my evaluation, may suffer.
but what the hell. i've been deprived far too long, and tomorrow i face the hell of call yet again. i deserve an evening of mindless surfing ^_^

Monday, July 19, 2004
12:42 p.m.

they told me to clear the list, so i did my best

post-call, friday and sunday, subspecialty: GI, heme/onc, neuro.
neuro patients give me no trouble at all. every now and then they need some tylenol, or the nurses need orders clarified (my writing is still neater than a lot of other residents' here, but not by much...and not for long, i'd wager), but otherwise they're quiet all night.

our own patients on GI are a bit more complex this time around, a bit more harder to manage.
a bit closer to death, for some.
we had two such patients, one an elderly gentleman whose family went through the death of his wife already, and once the situation was explained decided to make him DNR, in accordance with his wishes as they understood them. sad, but fairly peaceful; we pulled his tubes, stopped IV fluids and meds and had only a sub-q set for pain relief. i spoke to them several times, explaining what i could, and they seemed composed and maybe even grateful for my semi-anxious hovering.
he was about to be pronounced as i left the ward; not my patient, so once the night is done it was his doctor's duty.

the other is not so easy: a fairly young man, at least in internal medicine terms, a livelong alcoholic and in terminal organ failure. we're still giving him all supportive measures, including blood, but we don't hold out much (any?) hope.
he was awake while i was on call, conscious enough to sign a POA form and consents, but he never improved lab-wise. today, he is worse; it might happen anytime now, and i'm secretly glad he isn't mine. the POA is his barely-legal child, and i would not want to even breach a code status discussion, necessary though it clearly is.

the heme/onc patients are another matter entirely. some are here for chemo, and are doing quite well; others are barely hanging on. i had a code status discussion with one lady and her family, but then again it's easier if the patient is able to communicate, has had the illness for some time, is aware of the prognosis...and yes, is elderly.

with another, i sat up nearly all night, juggling stat blood results, fluid cultures, blood products, clinical pictures, panicky calls to my senior, calls to the consulting services, even online investigations of exactly what could be happening with the man.
he was too far gone to consent to anything, and his family wouldn't be in until daytime; they were coming in from somewhere. and of course, no code status - why is this ever left to the on-call off-service resident? this should never happen.
he survived, at least until today. at least until i could hand over to his own team, and leave them with the unpleasant task of family meetings.

family meetings. code status discussions. decisions on starting potentially toxic drugs, decisions to wake up an attending (from another service, to boot), decisions on when to treat and when to merely follow repeat results. even small decisions such as not going up to assess every single patient, to trust one's judgement enough for a phone order; it is on call, with minimal to no backup for "routine" calls, that i am really a doctor.

but hey, call still sucks. i must be very sleep-deprived, to even try to wax poetic about it.
ah, and i did an ABG yesterday; a tiny highlight in an otherwise miserable night.

Tuesday, July 13, 2004
05:45 p.m.

"it's made a lot of people a lot of money"

on tuesdays we have journal rounds, where three unlucky residents (yours truly goes next week) get to present some recent paper.
they feed us well; the only rounds at which we're fed, in fact. it makes it slightly more tolerable.
today a senior presented a paper on a tool for predicting when people with colitis (crohn's or UC) would need early surgery: a blood test, c-anca and p-anca. afterwards, the wise greying attendings discussed how useless this test is, how expensive, and how the company that came out with it is desperately trying to make a bigger market for it.
it was originally intended to differentiate between crohn's and UC, but the only time that is really necessary is before surgery, and by then it should be pretty obvious from the score of biopsies and radiological tests. there is a small percentage of people with indeterminate colitis - and literature has shown that for them, this test is next to useless.
indeterminate they are, and indeterminate they'll stay; use of the test declined as it was shown to be of no use there.

the company suggested it as a screening tool for children with recurrent abdo pain. that's about 15% of the pediatric patient population; no one in their right mind is going to "screen" that many people at over U$400 a pop, when the diagnosis can be made clinically and radiologically and the looked-for outcome would be so low.

so they struck out, and now this paper.
a "consultant" from the company was listed in the credits.
according to my attending, this test is mostly useless and vastly over-used in the US, to no great positive effect. here we don't use it much, i suppose because we're more money-conscious.
"these people have a financial interest in it; that's horrible".
i think we'd have far less good research if it wasn't for pharmaceutical and med-tech companies trying to find uses for their products. but it does drive it home, how one must be careful when reading even peer-reviewed journals. you have to look for the agenda.

probiotics are trendy again
another paper concerned the use of a cocktail of bacteria (chiefly lactobacillus) in the treatment of hepatic encephalopathy. the results were positive, even if the study did need a couple more arms.
but some of the papers quoted in this new article were from the 60's, and one of the residents chuckled and observed how we're coming full circle, how things tried long ago (in medical terms) are becoming more popular once again.
on the heels of the previously mentioned paper, one attending replied dryly, "well, we have more expensive probiotics today."

furtively typing away
and now i must flee once more before they come; the computer/charting corner is small, and the heme/onc team usually hovers around stabbing at us with their eyes, likely thinking that there are a trillion lab values we must unearth and make sense of before our attending comes and why are you paltry GI people even here you don't care about lab values unless you want to do a procedure and OMGshe'scomingshe'snearlyheregetoffthecomputerNOW!

i don't have to do heme/onc, except for call.
and tomorrow, i may have internet at home.

Saturday, July 10, 2004
02:36 p.m.

once again, musings on residency

i want to blog, but about what?
not sure how to put my residency into words. it's strange to hear myself addressed, casually, as "doctor" by nurses and other health care staff.
patients i'd gotten used to months ago. patients don't know what the heck a "clinical clerk" is, so they'd either call be "doctor" or "nurse". my preceptors would sometimes call me "doctor" - for kicks or to reassure their patients that they're not about to unleash a mere med student on them, i don't know.
but nurses and allied staff always know, of course. so it's the address from them that really makes the most impact.

my current attending is excellent, all i could have asked for. he's a great teacher on rounds, and has a bedside manner i could only hope for. in fact, he won some sort of teaching award last year.
he makes mild fun of my med school and its DIY approach to medicine, but not maliciously. and while i was worried about starting residency with people from other, more traditionally didactic schools, i'm reassured by the fact that they don't seem to know much more than i.
basicaly, none of us knows much at all.

today i came into the hospital on my day off, to take care of my perilously mounting pile of discharge summaries. i prudently tried not to be seen, lest some senior concludes that i have no life and schedules me for weekend call until the end of time.
our team's clerk saw me, but i distracted him with the stunning and unwelcome news that he too had a mounting pile of d/c summaries - the senior apparently having forgotten to tell him that he's responsible for dictating on his patients.

other than that, things are rolling along fine. my apartment is being painted as i type, and computer techies are fiddling around with my machine's innards to see if anything is salvageable.
hopefully i'll be able to blog from home soon.

Tuesday, July 6, 2004
04:17 p.m.

shaking in fear...or is that asterixis?

tonight is my very first on-call as a resident.
the first time when i'll be making the decisions and writing the orders, without any supervision.

it's different on the ward during the day. i can run things be the senior or even the other R1 when i'm unsure; tonight, a senior will be covering the ER while i'll cover the wards.
the wards. not our ward.

i'm on something called "internal medicine subspecialty call". i'm currently on the GI service, and think i can handle what our patients may throw at me.
but i have no idea what to do about the neurology and heme/oncology patients. hell, we didn't even have those rotations during med school. i've never dealt with patients like that in a learning capacity, and now i'm their doctor for the night.

another R1, a classmate from my med school, was on subspecialty call last night. a patient had an infarct, and she had to do the EKG and interpret it, and make the treatment decisions.
am i up to that? possibly. she was, and we did after all receive the same education.
but god, i don't want any infarcts on my watch. give me endless whiny patients in pain, just nobody code!

ah, and to all you non-medical people who may be reading this: try to avoid hospitals in early/mid-summer.
that's when the new residents start their training, and trust me, we know nothing!

Sunday, July 4, 2004
04:48 p.m.

moore reveals: bush is evil incarnate

mom came over yesterday, bringing my chibis and new car.
nearly damaged car trying to wrest chibi cage out of it, but all ended well and they're settled in amongst my boxes and the piles of paper that came out of the boxes.
new apartment is beginning to smell like home...

we caught "fahrenheit 911" last night.
pretty good. pretty scary, actually. even with the obvious slant (the director doesn't even try for a semblance of objectivity), i'd say it's still a must-see documentary. i mean, americans and those watching american tv have had their "war" news slanted in the opposite direction for so long (thanks, CNN and fox) that watching this thing does a small bit to restore balance.
also, whoever watches it and still votes for bush is scary. i fully expect politicians to break election promises and lie to me about money, but this is too much.

still computer-less. will have to look into buying a new one, i don't think it's worth it to just get a new motherboard.
and internet-less. my god, i almost want to go in to work tomorrow, because at least i'll have access.
sad, sad.

Thursday, July 1, 2004
11:27 a.m.

happy canada day!

feeling patriotic, or merely happy that i get an extra day off before starting residency? hmmm...

in half an hour i leave my sweet hotel for my box-filled, non-internetted apartment. i must immediately find towels. and rags for dusting.
and stethoscope.
and, god, an IM or GI book! i start this crap tomorrow. waaahhh!

dear pointy shelly bought a house, and i now own my very first car. a 2000 mazda protege. i will see it on the weekend.

not much to say, i suppose. not much, and too much all at once. i'm terrified of starting on GI, with the senior post-call and leaving at noon. will i survive alone for 5 hours?
will my patients?