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Archive for the ‘Medicine’ Category

There was another cardiac arrest I worked on recently that was (more) unexpected. A neuro patient (weakness, muscle atrophy, etc) had an MRI late in the day and was kept overnight for observations mostly because he was still too sedated to go home during normal hours. Anesthesia went off without a problem, but he’s had some respiratory infections or pneumonia in the past so we were checking him every hour or so just to make sure he was doing okay and not having any issues.

At midnight he started having some respiratory noise and a little cough, but his lungs sounded okay, so it was likely just some tracheal irritation. At six he was pretty much the same as he had been all night, lethargic but rousable and able to move/walk/interact and mentally there. At seven a colleague ran into ICU and let us know he was either already dead or on his way.

There was running, there was gurney-ing, there was emergency giving of drugs and shocking. There were lots of chest compressions. During a round of these I realized that my recent trainer was correct, compressing along to the beat of a song definitely helps keep the speed and depth of compressions appropriate. Now, the two songs offered to me were “Another One Bites the Dust” and “Staying Alive.” Which you choose, I was told, was based on how cynical you are.

I really wanted to go with “Another One Bites the Dust” because as we know, the survival rates for non-anesthetic arrests are crap, and it amused me quite a bit. That and I really hate the Michael Jackson song. Wouldn’t you know that the one I didn’t want decided to nest its little irritating self into my head. I was grimacing even as I was in the midst of the CPCR because I HATE that song but it would not go away. Alas, I suppose that’s how it goes when it comes to my brain’s emergency defaults.

I wonder which song the King of Pop’s doctor preferred?

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I am in the midst of my small animal emergency overnights. Basically, I spend 12 hours a day, from 8pm to 8am taking care of ICU patients, hospital patients with treatments and whatever emergencies might come in for a week straight. I also field phone calls from worried owners who are trying to decide if it is worth the $160 to come in and have their pet checked out. You might think that someone worried enough to be calling at 4am probably has a valid concern, but you’d be surprised. Most people that call at odd hours do in fact have a valid concern, but some people… well, some people are still just crayzee to steal some of my favorite human med blog term.

Word to human med folks: PLEASE DO NOT give your animals tylenol/acetominophen. Great for humans and human babies, deadly to cats, and pretty darn bad for dogs too. And yes, if you are a human medical provider who brings your pet into us after you’ve poisoned them through your ignorance of species differences, we will judge you. In the back room, amongst ourselves, after doing our best to save your pet, of course.

We spent some time Sunday night (Monday morning, really) rounding on CPCR and the new guidelines on the human front, which were in part based on animal and specifically dog studies, so they’re useful for us too. What to do in what situation, best drugs, which things are useless, that kinda thing. Wouldn’t you know we get an older dog come in last night for a history of GI symptoms that just wasn’t looking so good? She went from not looking so hot, to us putting in an IV cath to v-tach within about 5 minutes.

Lidocaine didn’t do squat, procainamide kinda made the ECG look a little different for about 0.2 seconds and then she went into fibrillation. She was a DNR, so we just kinda stood and watched her go for a bit. But then the actual real doc in charge decided to go ask please if we could shock her, and about a million years later we got permission to shock her once. It didn’t do anything, unfortunately but not unexpectedly.

On the plus side, necropsy showed a giant tumor, so she probably had a good reason for deciding to die on us and cement in my head the CPCR review I had just read. Teaching cases are valuable, even if her poor parents were completely shocked and devastated. No one expects to take their dog in for inappentance, vomiting, and lethargy and have her drop dead just like that. Especially if they’d been in somewhere else earlier and told that she probably just has an upset stomach.

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Internships are about experience, unless you’re going on to a residency. Which most people aren’t or can’t anyway. Why would you want to get crap pay for experience you could (in most cases) get elsewhere along with better wages, benefits, and where you might even get treated like a real person?

Saying something like this is unpopular and frowned upon. But I still feel like it’s true. So long as you have good mentorship, does it really matter if you’re an intern or “just” a newbie associate? And don’t tell me that the ‘mentorship’ part is the difference. There are awesome mentors both in official internship slots and at private practices. There are also crappy places on either end.  And sometimes it’s not even that there are or are not good mentors so much as a problem meshing and working well together.

I just don’t get it. I could see myself specializing a couple of different ways, but none of them involve going into a random internship for general experience with no plans of residency.

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Today was an interesting day at the hospital. It was interesting on the medical side since I got to play with some of my favorite toys: allergies/dermatologic issue and behavior medicine. There were kittens too, which is always a nice bonus. And some blood draws that made me feel like I might be a doctor yet. The terrible, no good, very bad case from Monday is stable and happy, and seems to be doing quite well. It appears that no more urine is leaking into her abdomen at least. If the ureteral reimplantation takes is still yet to be seen. If not, she’ll have surgery to take out that kidney next week. She is happy and playful though, and as usual, her appetite is voracious. Today was busy in part because it’s the edge of a three day weekend, when everyone realizes, “Oh shit!” and decides to walk in at once. Finally got to leave after 13 hours today.

So, it would be fair to say it was busy, and even somewhat stressed since we had some legitimate emergencies come in including a foreign body ingestion and a basketball sized spleen. Also had a ginormous retroperitoneal abscess and an anterior lens luxation. Neat cases… in the medical sense any way. We have to handwrite our files and our discharge instructions though, which is a curse for me. I cannot write quickly. I joke about being dyslexic sometimes, but sometimes I wonder if I should do some research.

Reading, silently to myself, has never been a problem. Not a problem that I remember anyway, but I was a shy child and practiced a lot. Reading aloud is torture. I skip words and half sentences and I hate it. Writing is much the same. I don’t write things in the correct order. One particular doctor was looking over my shoulder as I wrote out a prescription today. I was writing in the patient’s weight (23.6kg) and wrote the ‘3’ first, then the ‘2’ and then the ‘.6’ which earned the comment, “dyslexic much?” I dunno.

Maybe.

I then got the drug all jumbled up as well, which made me wince. I didn’t mean to write the letters or words in the order I did, that’s just how it came out, and I have to be very careful not to skip ahead and leave words out when I’m writing. I have a helluva time saying things in the correct order too. You know that joke about drunks who are switching parts of or entire words around? I do that normally. Especially if it is something like “neoureterocystostomy” which, I later learned, is actually “ureteroneocystostomy” and I just had switched it. In other words, I am not so think as you drunk I am. On a daily basis. What really gets me though, is that I will even do it with a freaking keyboard! That ‘remember’ a couple of sentences ago was originally typed in as rememper. Thank MS for spell check. Oh, and could we get rid of the whole pbdq thing too? They are not my friends. In real life they wind up being a ball with a line straight up and down bisecting it (think of the greek capital phi) or being completely scribbled out so I can start over.

At least with keyboards and electronic records, or even a word program I can type and print them out with, records and discharges are less painful, way faster, and far more readable for any poor sap who needs to extract information from them.

ETA quotes/links that interest me:

Signs/symptoms: letter reversal or mirror writing, difficulty with word retrieval or naming problems (which is easily overcome, just describe what it does or looks like and people will give you the word), difficulty distinguishing between similar sounds in words; mixing up sounds in polysyllabic words (auditory discrimination), for example, “aminal” for animal, “bisghetti” for spaghetti (Doesn’t everyone do this? Most people seem to think it’s funny), and difficulty reading out loud, reading words in the wrong order, skipping words and sometimes saying a word similar to another word. Apparently dyslexia actually runs in my family too… as in, my dad. Still don’t think I’m actually dyslexic though… I can read, and well, after all. Isn’t that one of the big things?

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Being a professional is an odd headspace for those of us new to it. I have been a student all my life. Yeah, I graduated to secondary school, then to college and learned what life as a college student was all about. It was and wasn’t different than that of a high schooler in different ways. My college promoted responsible drinking, which is to say, they didn’t punish you for being smart and going to the health center (or your roomie for hauling your drunk ass there) if you drank to much rather than secretly hiding in your room and dying of alcohol poisoning. That was different from high school. And the easy access to pot.

Then again, that was probably just because I was too determined to get into college and follow my medical dreams to take advantage of the fact that one of the high school teachers dealt pot to students for nearly twenty years before he was caught/retired my senior year. Many of my friends smoked pot though. I still hold that if I was ruler of the world, pot would be legal and cigarettes wouldn’t be. Not that even in college I smoked much weed. I am a terrible smoker- I cough and hack and it’s just not fun for anyone. The high is fine, but getting there may or may not be worth it depending on my mood. Pot brownies on the other hand, those are good clean fun for everyone. I have fond memories of driving a (very) stoned friend to the store for brownie mix. Because that was how we rolled- no one was allowed to pressure anyone else to drink or smoke, and you sure as hell better not let anyone of your friends find out you had even thought of driving under the influence when there are plenty of folks about who would happily give you a ride for a tasty treat after the fact, or just the moral superiority and hilarity of watching your buddies behave like buffoons.

Undergrad was a good time. I enjoyed it. Not as much as some others maybe, but enough to have accumulated fond memories. I think being a humanities person had something to do with it though. Late night discussions about the history of the ramen noodle and the embargo on cuban cigars were always par for the course. Then I go and get myself into a professional medical school. Where people have NO humanities skills, FEW social skills, and can’t read literature or write a simple opinion paper. It’s all sorts of fucked up. You tell me you need a 20 page paper? I may bitch and moan, but there is no question I can get it to you by Friday if need be. Some of my soon to be collegues might have a heart attack.

How did you people get to (almost) be doctors when you cannot write? I have read some papers by these people, on topics of their own choosing, that made me want to scoop my eyes out with a rusty spork. Yes, they can do multivariate calculus (so can I btw, it’s actually pretty fun) but they cannot communicate in writing, and some can’t even do it verbally. The social and coping skills are to match. So I look at this group of professionals I will be sharing breathing room with for the rest of my career and I wonder.

I can do all the things they can do. To some extent, anyway, we all have our strengths and weaknesses of course. But I can do these things, AND I can also do other things. I WANT this to be my career, but I could make a living a dozen other ways too if I had to. So while I feel I am a complete and almost certified member of this professional circle, I also feel like I am still part of another circle. Another circle who knows that there is Art to Medicine, not just science. I hope that more of the folks in the one circle learn to come share my second circle with me too, or it is going to get lonely in here.

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Exhaustion? Failure? Surrender?

It is now a full day after the most important test in my life. Unfortunately, I do not think I am exaggerating. This test was years in coming and I have spent the last three and a half year and tens of thousands of dollars preparing for it. Then I had the privilage of paying $550 dollars in order to spend seven and a half hours in front of a computer screen taking it. I have had the last three weeks ‘off.’ Meaning that none of my normal duties were required, but I studied. And studied. And then happened to study some more from a different resource. I find out if I passed sometime after the new year

The days immediately before the test were an oddly surreal time. The thing, the thing that had been the focus of so much time, energy and pain was nearly at hand. There were moments of odd surrender when I knew that there was no time left. What I did not know by now was not going to be learned in the feverishly panicked moments that I spent reading over and over and going through lists once more. But during those panicky moment I KNEW that if I failed by just a little, just a few points, I would know that I should have studied that one chart, that one packet, just that much more closely.

I ate terribly. I did not exercise. I had beer, wine, and spirits in occasional blowouts or blowups of stress. My stomach began to revolt and tried to dissolve itself in protest. I did not enjoy the last few days before this exam. I would pass people in the hallways of the hospital and shoot random questions at them. What drug do they think would be most effective for this disease? If you open a patient up with this condition, what organ will you see first? What would these symptoms mean to you if the patient was from this certain geographical region. And, most of all, which bacteria/virus/parasite/fungus/toxin/etc causes X, Y, or Z? It would be accurate to say that this test consumed my life for a while.

Then, I went and took it and if I had to guess, I’d say I failed. But that’s what everyone says they feel like. Often with very colorful language just before they go binge drinking to purge the memories. I am no different. Fortunately, something like 90% of applicants that are qualified to sit for the test do pass it. So on that end, at least, odds are good, and that really is some small comfort. The misery loves company sort of comfort.

Today was an odd day though. There is still much I have to do, most of it on a timeline and all of it requiring a significant outlay of effort, but I feel entirely disconnected. I feel like I am severely hung over. I am exhausted and feel slightly sick. I am sore, my stomach is still unhappy, and I can barely stay awake. I want nothing more than to melt away and have no responsibilities for a good while. The fear that has been driving me is gone, and apparently in it’s grasp, everything else has been worn away. I’d be surprised if I do not come down ill with something after this, just because so much stress for so long and not taking care of one’s health followed by a break seems to be the recipe for a cold. I got the flu vaccine just for this, so that I am less likely to be taken advantage of by that opportunistic viral demon.

Now that the fear has faded, I hope I can learn to be a real person again in the oncoming weeks.

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What the hell is up with mood swings? Sometimes they make sense, if something particularly unpleasant or something awesome happens, it would make sense from you mood to become sad or happy. But I don’t really understand the random, for no reason blahs. Or worse, the sudden inexplicable onset of the desire to smash something into itty bitty pieces.

According to a quick google search, these swings mean that I may have manic-depressive tendencies, be deficient in B vitamins, or I may be smoking too much pot. That’s an interesting trifecta of possibilities, but I’m going to tend towards it being the combination of Boards happening soon, a paper and presentation happening soon, having to travel soon and the stress of feeling completely unprepared for all of them.

There are many things I could do to combat this. Go for a walk, meditate, medicate, prepare, plan, study. But actually enacting any of these possible plans would require a little thing called motivation which the anger has apparently eaten. Instead I am typing. Because it is a sideways activity, meaning it neither takes the energy fixing the issue would, nor does it aggravate it. Sideways it is.

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