Apply Yourself: The Code Pager

I had to laugh a bit this morning.

I am on call covering a variety of internal medicine units today.  And this includes carrying the first year resident code pager.

Bum bum bummmm… (*clearly, that is ominous music)

I had a wee bit of a struggle this morning.

No, nobody coded.  And everything so far from the medical end of things is stable.

I was nice and collected the pager from the resident on last night at 8:45, so he could get the heck out of here.  I took it and walked away and then realized that the pager he gave me was one of the new ones.  Not like the older clunkier version I have.

The best part about it is that there is supposed to be this thing called volume control and a vibrate function.  The worst thing about it is that I don’t know how it works.  The most stable factor is that I hate pagers!!

So, I wandered away assuring myself I could figure it out.

I looked at it and realized it wasn’t showing the time.  I worried it wasn’t on.  So, I started hitting buttons.   There are only two buttons… How complicated can it be?

Probably not my brightest moment.

It turned off.

I managed to turn it back on.

I flipped the screen right side up and upside down.   Multiple times.  And then I figured out how that function worked.

Somehow  I got to a volume menu.  I turned it up, I turned it down.  I couldn’t get out of the menu.  And I still didn’t know if I was actually connected to the paging network because the time wasn’t showing up.

My pager shows the time once it turns on.  Why wasn’t this one?

So, I started panicking.  I mean, I got the screen to say “Code Blue” once.  Does that mean I am currently standing in the middle of the hall hitting random buttons on my pager all the while I am missing out on the joys (or lack thereof) of resuscitation?

Then, I started catastrophizing.  I was going to fail my rotation.  Because I didn’t show up to a code.  Because my code pager hates me.  And clearly because the stupid PGY-1 doesn’t show up, the patient will die.  Because my quality chest compressions can’t be replaced.

Foolishness.

But then, I re-grouped.

It must be a pager problem, I said to myself.

I went to the library, went online and found pager instructions for the hospital.

I followed them… And I still couldn’t get the time to appear.  But, I did manage to inadvertently mute the pager.

Suboptimal.

I tried to follow the directions to un-mute the pager.

But, I found the volume button again.

Turns out, you can change the volume even while the pager is muted.

Or was it still muted?  It is actually hard to tell, because despite the setting saying mute when I hit the buttons, it still beeps every time I hit a button.

Yes, indeed it was.  A big “M” for mute sat beside my flashing blank clock.

I followed the directions again.

I made it to vibrate.  At least it was progress.  But the screen inverted again.

Somehow, after multiple attempts, I got the pager to beep again.

But, I still didn’t know if it worked.

So, I paged myself (bright moment here… I am still in the library).  It beeped.  Loudly and obnoxiously.

Now, how did I get to the volume thing again?

I got it all sorted out.  But, how did I really know it would work in a code?  And where is the time!?!

So, I hiked over to where the communications office is.  I have patients in that building that I am covering , so I figured it would be a two-fold trip… One to figure out where the frig my patients all are and the other to resolve my pager battle once and for all.

I found the patients.

I found the paging office.

The sent a test page.  It worked.  They couldn’t explain the absence of time.  And couldn’t fix it either.  But, in the process, they changed my pager setting to vibrate (ARGHHH) so their tinkering wouldn’t disturb the others in the office.

So, they sent me on my way.  And I fought (and tripped twice) the whole walk back to the main hospital while trying to get my pager to beep again (I hate the beep of pagers, so it is bizarre that I would be so determined to have this happen).

I succeeded.  In significantly less time than before.

It is progress, but it is a struggle.

Now, later in the day, I sat down to do some blogging while I wait for pages and I see that the daily prompt from the daily post is entitled, “apply yourself” in which it asks for a description of a time when you attempted to learn something that didn’t come easily to you.  The pager catastrophe of this morning definitely fits this criteria.  Working pagers never comes easily to me.  And this one was a particular challenge.

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From Hearts To Holes

It is yet another new rotation time.

Ah, the life of an intern.

Variety is the spice of life.

Some days I could use a little less.

As I have mentioned (here and here and here, for instance), I dislike change.  Starting new rotations never fails to stress me out, at least a little.  New expectations, new preceptors, new nursing units.  All of it can lead to pretty significant change.

I have been told on countless times that I am very adaptable.

Adaptable, yes.  But, I am a sad chameleon, the change isn’t fun to me.  I quite like consistency.

Although, I must admit, I am excited to be going into a less busy rotation.  And learning is good.  I like learning.  And relevant learning.

Jumping around like this will make me a good doctor.

Today, I went from the world of Cardiology to the world of Gastroenterology.

Thankfully, this isn’t as epic as the change from Surgery to Peds Emerg or Peds Emerg to Cardiology.  At least the two fall under the same Royal College specialty.  Big win.

Image from theunderwearer.blogspot.com.

So, as goes with the start of a new rotation, I have reading to do.  More than I do after I am a week in and more comfortable with the subject matter.  Tonight’s mission… Learn about the management of decompensated liver failure.  This, after a month of managing decompensated heart failure.  It is a pleasant change, to be honest.

On a completely unrelated note… My husband forgot me at work today.  In his defense, I walk home most days, but opted not do compliments of some snow.  In my defense, we did discuss that he would pick me up on the way to work this morning.  I thought it was funny.  Possibly because I frolicked out into the snow to met the car only to realize that it was not our car and our car was nowhere to be seen.  Better me than our unborn children.

This is kind of what I looked like when I realized he wasn’t outside and that it was snowing and I didn’t wear boots. Image from 123rf.com.

On a more related note, I listened to this song  while getting ready for work this morning.  Today marks my PGY-1 half done day. 

The White Coat

The white coat.

The thing that induces hypertension in millions.  The signature of medicine so strong that there are entire ceremonies dedicated to strapping them onto first year medical students as a symbol of things to come.  The harbinger of all things infectious.

I don’t like white coats.  Sure, the look professional, but outside of a lab, they are just not good ideas.  I have my reasons.  We will get to those.

My medical school has a policy that clerks are to wear lab coats on all rotations with the exception of psychiatry and pediatrics (family is preceptor dependent)… Don’t scare the p-patients.  By the end of one rotation, most people have ceased to wear them… Or at least they try not to except when lectured by administration or other senior staff.

To be honest, I am a rule-follower, so I wore it fairly religiously through the required core rotations.  But, for my electives and selectives… Not so much.  Except lab medicine… Because playing with formaldehyde and human tissue should not occur without a thin layer of protection of the lab coat I take home and wash with our towels (yum).

Why, might you ask, would I hate something that represents such a noble profession.  Well, I will tell you.  In organized bullet form.

  • They are gross.  White coats are worn in hospital.  Hospitals are places where sick people are.  Sick people have germs.  Germs get on white coats.  White coats go from person to person and drop the germs behind them.  Delicious.
  • White coats are white.  Therefore, they get dirty, well, visibly dirty faster than most other colors.  Big pain in the neck.  Mine has pen stains and coffee stains generally by day 2 of wear.  Nothing coffee loves to fall on more than a fresh white coat.
  • They are not temperature friendly.  White coats are convenient if you are cold.  They can make you warmer.  But not warm enough that you stop being cold.  The reverse, however is untrue.  A white coat is not cool enough to keep you from broiling to death.
  • They are yet another thing to bring places.  As a clerk at my school, we are required to travel a fair bit.  Packing your white coat is not at the top of your priority list.  It usually gets jammed into the top of a bag or forgotten.
  • White coats scare people.  I don’t want to scare people.  I want to help them.
  • White coats represent a lot of what I don’t like about medicine.  The paternalistic old boys’ club past.  The elitism.  Ugh.
  • They make you stick out.  Everyone not medical assumes because you are wearing a white coat, you are clearly a doctor and therefore know what you are doing… WRONG.  A proportion of people who are medical sorts assume that you are a clerk.  This is good because they then know your appropriate knowledge level.  But then, they ask you questions excessively in rounds.  And you get volunteered for the not-so-fun jobs.  And then you get grilled more.
  • They have pockets… And the pockets get filled and then they get heavy.  And you develop this weird shoulder pain… That is bilateral.  And you can’t figure out why.  Until, at the end of the day, you remove your white coat.  And suddenly even your giant winter coat doesn’t seem all that heavy.
  • They get caught on things.  Stair rails, bed rails, door knobs… You get the picture.  I am a klutz.  The white coat does not help the situation.

As you can see, the white coat can cause a whole whack of trouble.

It has a good point, though.  The only redeeming quality of the white coat aside from statistical significance are the pockets.  Ah, the pockets.  You can keep a lot of stuff in a white coat.  Papers, notebooks, iPods, pocket guides to everything, little pen lights, pens, post-its, lists, a snack for when you get hypoglycemic after rounding for hours… The list can go on and on. Heck, you might look ridiculous, but a water bottle could fit in one of those pockets.  I may or may not have tried it once.

I am not a fan of the white coat, except for the pockets (until they cause strange shoulder injuries).  It represents much of medical history, but in an age when we are so well educated about infection control and patient centered care, it is ridiculous to strap them on outside of a special ceremony.

**This post reflects my views only and not the views of my peers (okay, well most of the people I talk to agree, but not the others) and definitely not of my medical school (which outside of the white coat thing is lovely).

Related posts:  White Coat Problems (sugarandscrubs.wordpress.com), Doctors Should Stop Wearing White Coats (getaheadwithdrg.wordpress.com), Why Doctors Wear White Coats (numberneededtotreat.wordpress.com), Why do Doctors Wear White Coats? (slate.com), Considering the Significance of a Doctor’s White Coat (medicallessons.net).

Top Ten Medical Books

This week, I am teaming up with the Broke and the Bookish for Top Ten Tuesday’s Top Ten Books of Genre X.  Its like a choose your own adventure.  I get to choose my very own book genre.  That is a bit of a problem.  You see, I like a bit of everything, much like my taste in music.  I flit between so many genres; I could be reading about a historical event one week, vampire drama the next and medical mysteries the next.

I have been contemplating all day (because clearly, what I should be doing while at work and on call is deciding what I write about in my blog).  I came to the conclusion that my last four years have been spent reading an inordinate volume of medical literature.  Probably good given I want to be a doctor when I grow up.  A little sad because I should have made more time to read for fun. I am also starting to feel the pressure from my lovely peers to study for the LMCC (my giant licensing exam at the end of four years of medical school that is now looming).  So, today, while waiting for consults, I cracked open an Internal Medicine textbook for both the benefit of the last few days of this rotation and for the benefit of my guilt.   And thus, I came to a conclusion of my topic…  The top ten medical textbooks.  I am such a geek.

Toronto Notes.  This is the first book on my list and my number one favorite.  It is literally the book with everything you need to know for the LMCC (literally, that was its purpose).  It is generally in point form with well-phrased brief paragraphs, clinical pearls in the margins and lots of easy to use diagrams and charts.  Plus, it is divided up by specialty and comes with perforated pages, so that if you want to, you can remove a section and put it in a binder (because it comes hole punched) (I am incapable of doing this because it is like defacing a book).  The sucker also comes with a pocket book, and access to a ton of online resources.  Awesomeness.  If only it didn’t weigh more than an infant.

OSCE and Clinical Skills Handbook by Katrina Hurley.  Written by a grad of my medical school, this is a resource that basically helped me survive second year medicine.  It is an all-inclusive preparatory guide for the Objective Structured Clinical Examination.  An exam that induces fear and strife into medical students everywhere.  This guide summarizes techniques and the rationale behind physical exam and history taking, gives sample scenarios and scoring and is conveniently distributed by body system.  It is a bit basic for higher level OSCEs, but the basic skills are necessary for all exams, not just the ones in second year.

Rapid Interpretation of EKGs by Dale Dubin.  This book was recommended to us in our first year Cardiology course.  I wish I had one of my own instead of borrowing from friends or the coveted library copies.  The thing is, they are out of print because buddy who wrote it got in some very serious legal trouble (not that I condone his legal trouble, but why remove a perfectly good and unrelated book from the market).  It dumbs down EKGs in a way that I haven’t found reproduced and in a way that makes me look at least ¼ less stunned on the wards.

Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine.  This was a must-buy for me.  All of the medicine residents have them and swear by them, so I acquired an online version.  The pocket manual is reasonably sized, but only fits in larger pockets.  They have fantastic summaries of all of the common diseases, presentations, differentials, treatments, and tests.  It is great for when you are in a pinch on call or on the floors.

The Case Files series.  This is a series of books by various authors that present all of the common specialties in a case based manner with multiple choice questions and written explanations, as well as additional information based around the case.  I found it to be a great study tool and useful when there is only time to read for a brief period.  The best one of all was the Obs/Gyn one, I found they are all variable in quality, but all were helpful in some way.

Tarascon Pocket Pharmacopoeia by Richard Hamilton.  They make a ton of these yearly.  And just for clarification, I am referring to the lab coat one, which contains drug information.  Though, I also own the oncology one and it is delightful, as is the differential diagnosis one…  Back to the subject at hand… I would be lost without it.  It contains the indications, dosing and route for most of the drugs on the market with the variety of names they go by.  And it is so small it fits in a normal sized pocket.

First Aid for the Medicine Clerkship by Kaufman, Stead and Rusovici.  This is another useful one for studying in clerkship (obviously, just look at the title).  I generally don’t like point form books, but this is another one that is great to skim at the beginning of a rotation or near the end.  It is subspecialty based and offers summaries on the common diseases (and some less common), presentation, physical findings, differential diagnosis, labs, imaging, and treatments.  It also has little notes on the side that offer fun acronyms or ways of remembering information, for instance, “Argyll Robertson pupil: Like a prostitute, will accommodate, but will not react – the pupil accommodates, but is not light reactive.”  Thank you First Aid.  I will never forget that again.  It also gives tips on how to survive the wards and how to do well on rotations.  Helpful if it is one of your first rotations and you want to know how to look at least somewhat less stunned.

Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple by Richard Preston.  This is another comeback from first year, but this time compliments of the nephrology course.  I don’t know about others out there, but this stuff never seems to stay in my head.  This is an easy to read, and somewhat entertaining description of the presentation, pathophysiology and treatment of all things acid-base and electrolyte.  It even has sample problems at the end of each chapter to make sure you get it before you go experimenting on humans.

Robins & Cotran’s Pathologic Basis of Disease by Kumar, Fausto, Aster & Arbas.  Most people groan at this book.  Because most people seem to dislike pathology.  Although it is not one of my favorites, my selective in it in January plus my fascination with why and how things happen seem to make it more appealing to me.  This book has something for everyone… Lots of pathology and slides, but also good summaries of diseases and fabulous explanations of pathophysiology, which is my big selling factor.  The book is a fortune.  I have a smaller med student version, but got to use the big one on my selective and nearly read the entire thing in the two weeks (this is a testament to my geekiness, my speed reading and the amount of “reading time” I had).

Case-Based Neurology by Anuradha Singh.  Neurology is probably my biggest challenge after nephrology.  And our neurology course is a beast, so this book was my buddy.  I remember better with cases and this also had lots of diagrams.  Plus, it wasn’t a terrible read.

I also have an honorable mention from my Nuc Med days:

The Pathophysiologic Basis of Nuclear Medicine by Abdelhamid Elgazzar.  Such a great book.  Plenty of images, well-written explanations in way more detail than any normal, reasonable person would want.  It talked about the pathophysiology of every disease and every imaging technique in use at the time of writing.

What are some of your favorite medical books or other textbooks/reference books? 

“That clerk”

You never want to be “that clerk.”  And yet sometimes you do…

Do you know what I mean?

“That clerk.”  The person who did either stupid thing x and is now famous for it.  It can also be the person who did ingenious thing y and is now known for it.  But really, 9 times out of 10 it is stupid thing x.

I had a “that clerk” moment today.  Not quite a world-renowned “that clerk” moment, but enough to be famed about the internal medicine wards in the particular hospital where I reside.

The story that makes me “that clerk.”  Patient with acute renal failure has a central line.  This is his second in the last week and it seems to be bleeding and there is nothing to draw back.  Perhaps it is coming out a bit, but the site was just redressed, so maybe check the ports.  Solution, send clerk and doctor to go check it out… Clerk cannot draw back from first port… Or second… Oh wait, they are clamped.  Point: clerk!  First line, no flashback, but no backpressure, second line, no flashback, but no backpressure.  Third port… Patient bellows. While concentrating on unclamping port, I somehow (unsure exactly how) both sprayed him in the eye with saline and a good bit of the dressing at the line was also soaked.  After profuse apologizing, I check the third port… I get flashback and flush, but then I look at the site more closely now that I adequately salined the entire area (whoops)… Turns out the entire line appears to be pulled out more than it should be.  Had I not soaked him with saline and needed to change the gauze dressing, we may not have noticed as quickly.  A chest x-ray shows that the line is displaced quite high in his jugular.  In my defense, I did not do that… The line is sutured in and it was out below the suture line.  We need a new line.  Again.  Ugh.

So, I am “that clerk.”  The clerk who attacked a patient with saline in the eye, yet discovered an incorrectly positioned port that we otherwise may have said was okay.  A mix of good “that clerk” and bad “that clerk.”

As a clinical clerk, you develop a bit of a complex at times, when people say something about “the clerk.”  Probably because a good chunk of the time, it is not good… Incorrect orders, a problem or just more work to do.  That is the beauty of being a learner.

One of my favorite “that clerk” stories involves one of my friends.  Her first rotation was general surgery and she was ridiculously excited.  They were in the OR and the attending she was with was using the hand sanitizer type scrub solution.  There is a foot pedal to press to have this administered.  Her attending told her that if she put her hands under and said “Abracadabra” that solution would come out.  She didn’t believe him, but played along and it worked!  So, he strung her along like this all day.  And the resident perpetuated it more the following day.  Finally, they didn’t hit the pedal when she said “Abracadabra”.  She was confused.  They had to break it to her.  Needless to say surgeons all over town joke now by saying “Abracadabra” when getting the scrub solution.  Someone went on an elective elsewhere and the surgeons there knew.  Word travels fast.

One of the attendings tells us the story of how he was “that clerk” because he didn’t know how to work the Dictaphones properly and spent his entire first clerkship rotation dictating what he thought was correctly.  Then, he got an angry call from his attending a week or two after his rotation ended to say that none of his dictations were completed.  Turned out he wasn’t hitting the complete dictation button.  He had to re-dictate everything.

A good “that clerk” story is one of a clerk who, when asked to do an ECG on an elderly patient with chest pain noticed a palpable lump in the patient’s breast.  With further assessment, the patient was diagnosed with breast cancer and required further management.  The lady had been ignoring the lump as “nothing.”

The good thing about “that clerk” stories is that you learn.  You learn to check for things before you act.  You learn to not believe everything people tell you.   You learn to be on your toes and be observant and keen.  You learn how to not be “that clerk” and to be “that clerk” and to laugh at yourself when you have “that clerk” moments.  It is through these moments that you grow into a doctor.  Somehow.  At some point.  And even then, you still have moments.

But, life lesson… Don’t shoot people in the eyes with normal saline.  Especially when they didn’t like you that much in the first place.  Even if most other people found the whole thing a little funny.

Have you had a “that clerk” type moment before?

Fun waiting for a call

Day 2/3 on call.  How exciting.

After rounding this morning, I am free to hang out and wait for a call.  The beauty of home call is that I get to do it from the comfort of wherever I want within 15 minutes of the hospital.

Now, I am not at a loss for things to do… We have cable, so I watched the movie My Girl and am hanging out on the couch with Patrick.  Not bad.

It got me thinking of ways we have kept ourselves entertained on call over the past two years.

  1. I was on call… I didn’t need entertaining.  I was working.  I like real people.  In fact, I almost didn’t have time to eat!
  2. Eating.  Because you just never know when you will get to eat again.  And everything looks delicious at 2 in the morning.
  3. Napping.  Not on purpose, but full on narcoleptic episode in First Aid for Medicine.
  4. Ordering large volumes of take out from your favorite Indian restaurant…  Wait, that is food again… Whoops…
  5. Super bowl party.  In a patient lounge in the hospital.  With a few of the patients.
  6. Food scavenger hunt through hospital.  You can make amazing ice cream sandwiches with those little ice cream cups and arrowroot cookies.
  7. Hospital based work-out… Running the stairs.
  8. Field trip to the gym (on home call).  All fun and games until your pager falls off and explodes into 6 pieces (see this post) whilst on the elliptical.
  9. Board games!!!
  10. Reviewing ACLS protocols… When you get an answer wrong, someone would press the “test” button on the code pager… Negative reinforcement at its finest.
  11. Knitting.
  12. Baking.  This is less complicated on home call… But can be rendered problematic when you actually get a call.  In hospital, it presents an additional challenge.  Though, once we baked cookies in the hostel lounge.  And ate all of them… In one night.
  13. Hang out with the hospital mice.
  14. People watch in the cafeteria.
  15. While on home call, trying to do all of your errands (grocery shopping, bills, cleaning) before getting paged.  This gets especially challenging when the pager goes off when you are in the middle of something.
  16. Sundae Sunday at the children’s hospital.  Best. Idea. Ever.
  17. Wii tournament… At the children’s hospital.
  18. Caroling at the hospital (thank you medical school choir).
  19. Studying for exams… Well, having a USMLE world quiz race.  Best time and score wins.
  20. Practicing casting on each other… Then getting paged.  While you have a cast on your arm.
  21. Delivering fake babies from a fake pelvis.
  22. Trying to make embroidering patterns with sutures in a pillow case.
  23. Crossword puzzles.  Group effort.
  24. Hockey night in the hospital or the M household (depending on the brand of call).
  25. Listening to music.  And playing guess the next lyric or guess the singer or guess the song.

So, as you can see, there are many things to do on call… Most of which involve food.  When there isn’t real work to do.

Slow calls are both a curse and a blessing.  They are great because you aren’t “real” working, but you are constantly on edge waiting for a call and sometimes, especially in hospital, even with the awesome aforementioned things, it gets ridiculously dull.  Plus, when you get called you are so lazy from sitting and waiting that you are bitter that you have to do something.  At least that is what happens to me sometimes.

Sometimes in life we sit and wait for something.  We may do other things to distract ourselves and hope the inevitable doesn’t happen.  The other things may be fun or productive, but in the end, there is something else we are waiting for, something else that will happen, something else that technically takes priority.

Right now, waiting for Match Day, I am distracting myself with all of the things that I do while on call, plus the call itself.  Match Day will come no matter what.  And it takes some sort of priority over these other things.

In life, we have a greater purpose.  Sometimes, we waste time doing other things when perhaps we should be doing something else, or when we get the call to do something else.  Like a pager, we shouldn’t ignore those calls.  Maybe it is to do something “crazy” like work overseas or maybe it is a simple as bringing cookies to a neighbor or calling a friend.  God may be paging you (sort of), but the thing is, you need to answer.  Distractions are fun, but we need to have priorities.  We need to do the work we are put here to do.

For now, I will hang out in the living room and listen to music whilst reading the greatness that is The Hunger Games and wait for a call.

Dreaming of the Match

I hate nightmares.

Mainly ones that involve scary things like serial killers and such.

But, ones related to school/work have a different element of fear induction.  Because they are often just a touch more realistic.

Last night, I had a Match day nightmare.

In just over three days, I will know where I will be living and working for the next five years.  It will be Match day.   It is both thrilling and terrifying, but definitely nightmare inducing.

I dreamt that I was still stuck out here on call on Match day. Not sure how I managed to get sucked into 5 days of call (especially when I took leave for Monday and Tuesday), but anyway, I had to drive back to town to get my match results and celebrate with my class.  I was running late and somehow forgot to check the computer for my match results.  But I didn’t notice until I was in the student lounge with everyone celebrating.  Everyone was asking where I matched.  And I didn’t know.  So, a girl offered me her computer (her giant, old school PC apparently), which was old and slow and kept signing me into her CaRMS account, not mine.  So frustrating.  And my phone wouldn’t work.  And people were starting to say I didn’t match.  Then we checked what apparently was the “master list” and I wasn’t on it.

Then my alarm went off.

Thank goodness.

I haven’t been overly nervous for Match Day (overly being the operative word).  But that dream really threw me for a loop.

I do tend to dream about things that are a focus for me and not necessarily a big worry, just a focus.  When I have school dreams, they are generally about the material I study, not failing the exam.  So a dream about not matching is kind of odd, and yet not so much.

I remember, in Hematology, I dreamt our class was required to give one another chemotherapy as a part of the curriculum.  So we could know what it was like.  We had to rock paper scissors to see which half would receive treatment on the first day.  Weird, I know.

During my Internal Medicine rotations, I once dreamt Patrick was having a heart attack and that I HAD to get him 325mg ASA to chew or he would die (this is something you give, but it being missed would not kill a person).

During Pediatrics, I dreamt I gave birth to premature (wait for it…) puppies via C-section (I have a desperate desire to NEVER have a C-section).  And everyone thought they were beautiful and doing well.  Except I knew there was something wrong with them… They were, well, puppies.  After delivering said puppies, I shared a room with a little girl in DKA (diabetic ketoacidosis) who kept throwing up everywhere.  I couldn’t find my puppies and nobody would visit me because of the barfing child.

You get the picture.  I have weird dreams about work.  And not the kind that are terrifying in an outward sense, but just bizarre.  So, the Match day combined the bizarre and what, for me is almost my worst nightmare, though I never actually not matched.  I just couldn’t find out where or if I had.

The good thing is that I am on call all weekend.  And Patrick is visiting.  Thus, I will have plenty to distract me from my Match related angst and thoughts.  I just have to refocus and potentially have weird medicine related dreams… Or normal ones.  Normal is preferred.

The other good thing is that very soon this part will all be over with and I can start planning for the next chunk of our lives.  I trust that God will provide and match us to the place He has prepared for us.

Have you had any ridiculous or scary dreams about work or school?  What about bad dream remedies?

Too much of a good thing… Learning from the evidence.

Oxygen could kill you?

Who knew?

I knew it could give premature babies retinopathy, but critically ill adults?  Seriously?

Before you start to panic and demand physicians everywhere to remove oxygen from grandpa, allow me to explain…

Today, we saw all 6 of our patients in the first hour and a half (I saw them twice).  We didn’t have clinic scheduled today because the call schedule was late coming out and he doesn’t like to have patients scheduled on call days.  On a related note, we found out that we are on call all weekend.  ALL WEEKEND.  Surprise!   Not impressed (**whines).  Anyway, he decided it would be a good idea for me to go home early today (no complaints) but to read a few journal articles to be ready to talk about them tomorrow.

I am a big geek, so no problem there!  He suggested checking out last week’s Archives in Internal Medicine because it was interesting.

So I did.  And this is what I learned.

Something that caught my attention was the article Supplemental Oxygen in Medical Emergencies: More Harm Than Benefit?  It discusses how research is starting to point to the fact that our instinctive strapping on of oxygen to every sick person is not always good.  That people who are having ischemia can actually have more ischemia on oxygen.  Increased oxygen concentrations in the blood can cause vasoconstriction and free radical formation.  Thus, they can increase ischemia and tissue damage.  People who receive high concentration oxygen with normal saturation on room air can have poorer outcomes.  Wild!

I did further reading and found articles about oxygen administration and how we tend to over use oxygen outside of guidelines for requirements in hospitals.  The cost savings from more appropriate usage of oxygen would be ridiculous.  One study quoted 45% of oxygen administration is not medically necessary.  Plus, with what scientists are discovering about oxygen, imagine the impact.

I read another article entitled Effect of Aspirin on Vascular and Nonvascular Outcomes.  This was talking about the use of aspirin as prevention of cardiovascular events, cancer and death.  Interestingly, despite the medical profession’s view of aspirin as a benign drug, it still has side effects and in this study had no impact on cardiac death or cancer mortality.  It did reduce non-fatal MIs.  But the authors suggest that this needs to be weighed with the bleeding and GI side effects of the drug.  Crazy.  I have been in clinics where aspirin is prescribed to patients with any cardiac risk factors, even if they have not had an MI.  But apparently it is in people with known cardiac disease that it has shown benefit.  This is not to say there is no benefit.  Just that you need to think before prescribing or leaving it on the person’s drug list.

I don’t think I will stop giving oxygen to sick patients… If they need it.  But maybe I will re-evaluate more closely those who are receiving it and may not need it.  I will still prescribe aspirin, but maybe not to the healthy people with no risks and I won’t be as scared to remove it, especially with side effects.  I am still so new and learning.  But it is good to learn these things and the balancing skills now, before I am on my own with no preceptor to approve and co-sign my decisions.

Reading these articles about things that are so common, so reflexive in practice got me thinking.  Why do we do what we do?  We pride ourselves in being evidence-based, but do we always look at the evidence?  There are some things we do based on clinical experience or habit that are not necessarily the best.  Like ordering blood work every day.  Not always necessary.

Not that reading a single article on a topic will make me change my practice, but it should make me think about what I do.  Consider change.  Consider further reading.  Sometimes there are different subtleties in a research paper.  It takes more than one positive or negative study to really make changes.  But, even one should make you think.

I think it is good to think about why we do things.  Especially in medicine, but also in real life.

I set alarms for only 3 or 7 past an hour.  I have for years.  There is no evidence for this.  I am clearly just bat crazy.  But I think about why sometimes.  I think it is to give me an extra few minutes of sleep.  And because my OCD won’t allow me to change it.

I have a side of the couch.  I get agitated and anxious when someone sits on the other side.  Does that mean it is proven to be bad?  Nope.  I am just nuts.

But these are things that cause little harm (except to me and my poor spouse).  What about bigger things?

I drink coffee most every day.  It is a habit.  It isn’t the best habit.  It isn’t the worst.  If a research article comes out saying caffeine causes cancer, will I stop?  I don’t know.  Honestly, probably not.  It would take more than one article.  It would likely take first hand clinical experience.  But, is that what smokers once thought?

But bigger than that… Why do I go to church every week?  Why do I read my Bible every day?  Is it some sort of routine or ritual or is it something that is proven or real or legitimate?  For me, it is definitely the later.  I may not always be entirely realistic with my routines or rituals, but lets face it, church and bible reading and such, they aren’t as fun to most as drinking coffee or even sitting in a designated couch seat (though I admit that when the seating in church is really off, it bothers me a tad).  I feel like I need to test those desires, to make sure they are legitimate on a regular basis.  I need to worship God for who He is and what He is.  Not because I did it last week.  I need to do it because I know it is proven to be a good thing.  I see it in the lives of others, I read about it in the Bible.   I feel it.  I know that won’t be disproved or disputed.  At least not to a significant degree.  God is one of the few things we can’t have too much of.

I love reading about medicine.  I love learning about progress and how things affect our bodies and how the practice is shifting.   I especially find it crazy when something I thought to be so second nature, so common turns out to not quite be the best thing.

We can have too much of a good thing.  Just because it is what has been done for 50 years does not mean it is the best thing.

We need to evaluate our practices, both in medicine and in life.  Are our action the best for the circumstance, or do we need to adjust?

Kind of like undergrad with moose and a book.

Patrick is driving up to pick me up after a week of Internal Medicining it up in my new favorite rural community.  I have my suitcase all full of laundry and a plan to hit Jungle Jim’s on the way home, but not to hit any moose (because that is bad).

Living here has been nice.  Much better than the CaRMS tour.  Less rock star hotel hopping and more second home like.  Except its still not home because my cooking ingredients are limited and I am down a spouse and a car.  Plus, I get quiet nights listening to music and reading on couches with the roommate (or listening to her try to get her parents to Skype… Best moment of all “Dad, I can’t see you its too dark.” “But the lights are on.”  “Well, it is pitch black.  Do you have something on the webcam.”  “Oh, maybe that plastic on the webcam has something to do with it.  I didn’t want to take it off until I was sure it was safe.”  “You think?  Take it off.”).

Patrick was warning me that he was not going to do all of my laundry when I get home because I am now a “grown up.”  He was joking… I think.

This whole living in an apartment with a friend from school is like university.  I go home on the weekend and do my laundry, see my friends, mooch food and then I come back here.  To a world of work and hanging out with the roommate.  I think it is kind of like undergrad.  Living in res.  Except with work and no parties (unless you count when we watched The Big Bang Theory and Parks and Rec last night).

Oh, and I don’t have a car.  I had a car in undergrad (except first year).  I do not have one here.  So, I walk.  Down the giant hill in the morning (not bad except when it is icy, then it is kind of like luging on my feet) and up it at night.  This is the biggest hill of all.  It winds so it is easier for vehicles to get up.  And easier for me to almost get hit repeatedly by fast driving cars going around the turns.  Interestingly, there is no gym here, but I am still getting in great shape with the hike up said hill.

On a bright note, I did not get called last night.  There were two consults in the middle of the night, but the doctor did not call me because he didn’t want me to get run over walking down the hill in the middle of the night.  Very much appreciated.    I like my body in one piece.  And my sleep.

Good thing too… This whole only one drink other than water thing would have been problematic if I was sleep deprived.  Hello coffee cravings.  Stronger than the ones I get anyway.  My original undergrad brought about that whole thing.  Before university I though coffee was gross.  Darn Tim Horton’s in both the hospital and library.  I drank a lot of coffee.  And juice.  I still do normally.  This is making me very grateful for tap water, though.  So cool.

Okay, so its not like undergrad at all… No coffee, no parties, no papers to write (minus blog), living with one person in a nice apartment, “working” (but hardly… easiest week of Internal Medicine of life).  But let me imagine.  I lived at home during my undergrad.  And likely would have hated res.  But still.

The drive home should be fun.  The beauty part of living in this lovely island of a province is that the place is infested with moose.  We don’t have deer or skunks or snakes… But moose.

Bull moose browses beaver pond near Grand Tetons

Image via Wikipedia

They aren’t even native to here.  Some idiot about 200 years ago thought they would thrive here and make good food… So he brought a few over.  They thrived all right.   Moose are a serious problem.  They kill people.  They are so huge that when your car hits one, they crush you, kill people on impact.  Ridiculous.  So, the province has installed lots of signage warning about moose.  There are moose sightings on the radio.  There are even “moose sensors” on the highway (these are new)… They flash if a moose moves between two of them… I am fairly certain that most days you see the moose before the lights.  I don’t want to test that theory.  You get conditioned to looking for the moose.  You don’t drive at dusk or dawn if humanly possible.  They are beautiful.  If they are very, very far from the road.  They are also delicious to eat.  Moose hunting is big here.  And they are giving out more licenses now… To control the population.

Jungle Jim’s (the restaurant, not the supermarket), however, is native to this lovely province.  It too thrives.  There are a ridiculous number of Jungle Jim’s.  The theme song is on every radio station at least once an hour.  I swear.

On my last aside of a very tangential post, I am reading Hockey Stories Vol. 2 by Don Cherry.  Very light read.  Very fun read.  It is written in a very bounce around, random story style.  Kind of like this post.  I haven’t read volume 1, but I got this book for Patrick for Christmas last year and he really enjoyed it, so I thought I would give it a try.  I do like Don Cherry, even if he is random and ranty and a bit on the questionably senile side.  I want to be that spry when I am his age (he says saunas keep him going… Mental image is nasty.  I hate saunas, so that can’t be my trick to staying spry).  The book has stories about his adventures doing stuff for Hockey Night in Canada, as well as his days playing hockey and raising his family.  I have to say, the guy comes off as crazy, but he makes some good points about player safety and respect and supporting the troops.  If you are looking for something light and humorous, this is a great one to pick up.

It’s call day

Today commemorates my first real day of call in about 8 months (6 if you count the ER shifts I did during family medicine that one weekend, but lets get real, they did not count).  The beauty of fourth year is that most rotations you do, you don’t have to do call and if you do, it is generally voluntary.

This call is not voluntary.  Just saying.

I am very out of call practice.  Especially when it is at a strange hospital with a new system.

At least it is home call.  Though, I don’t have a car, so really, that poses a problem.  My favorite roommate has volunteered to drive me/let me borrow her car for the night.  Thank goodness.

I tried to hint that call is not usually required of us politely by saying that I haven’t had to do call on my selectives.  Nope.  And then I pulled the whole, it is a 15 minute walk to the hospital, so don’t expect me right away.  Nope.  No response.  Just a “hope we have a quiet night.”

My call karma (that means my luck with having a “good call” — few consults) is about 50/50.  Sometimes I get slammed, or other times only one or two consults.  Thing is that they generally get anywhere from 3-5 consults per 24 hour period.  5 is a bad day.  I have done 2.  What are the odds?

Bright side… I don’t have a pager here, so he calls me on my cell… And it plays “Don’t Stop Believin’.”  That makes everything a little better.

I am not really complaining (well, I kind of am).  I do think call is a great opportunity to learn.  I would feel better about it if it were easier to get to and from the hospital for me.

Amazingly, the whole routine for Internal Medicine consults has flown back into my head.  Even the starting doses of Plavix and such.  Crazy how something gets drilled in and somehow lives back there somewhere.  So far, we have admitted two heart attacks.  Not surprising, given that most of our currently admitted patients are either in for heart attacks or heart failure.

The interesting part of Medicine call is that you never quite know what you will get.  Some cases are pretty straightforward MIs.  Others are twisted and convoluted House MD like puzzles.  I like those.  Just not at 2 in the morning.  Which seems to be when they like to come in.

Fascinating case that I had this one time (not this call)… 70-odd year old lady with jaundice (yellow) and fatigue progressing over the last 3 months.  History of rheumatoid arthritis and type two diabetes.  Deaf as a post.  LFTs through the roof.  No alcohol use EVER.  No smoking.  Giant list of prescribed medications for blood pressure, diabetes, cholesterol and the arthritis.  No infectious contacts.  No blood transfusions.  No travel… ever.  No family history of liver disease.  Physical exam showed a big liver (not huge, but about 16cm), jaundice, and a grade II/VI systolic ejection murmur.  Blood work showed elevated LFTs.  AST and ALT were elevated, as was bilirubin and ALP.  Thankfully, her INR and blood counts were normal.  She had a cholecystectomy years ago and no abdominal pain.  CT showed nothing.  We sent off serology for hepatitis, testing for a ton of autoimmune causes, levels of copper and iron.  We took her off of her cholesterol medication. We hydrate her.  She does not improve.  Her ANA comes back weakly positive, everything else is negative.  We do another review of her medications and ask about over the counter drugs again.  She had received no new prescriptions for years, but recently had a flare in mechanical back pain that had improved.  She was taking Tylenol regularly at home, but did not require it in hospital.  As it turns out, she was on hydroxychloroquine, which has been shown in a few case studies to cause liver failure very rarely and this likelihood is ever so slightly increased with use of other medications that affect the liver.  With no other options, we consulted the hepatologist and stopped her hydroxychloroquine.  Her LFTs began to improve gradually and she was later discharged to follow up with the hepatologist, as there was some remaining elevation in her LFTs.

Interesting how something that was initially not seen as a threat to her liver, as it is not one of the main side effect can, when combined with something else and possibly some other predisposing factors to lead to liver damage, that, thankfully in her case was partially reversible.

This was one of those “a million possibilities” but it was not the obvious.  So interesting.  Especially when there is a happy ending.

So, call (and beyond) can bring on some very interesting learning opportunities (geeky snort).  Plus, sometimes the things that you see or hear are entertaining… Like the patient today contemplating my age and connections to people around town on the other side of the curtain from me.  Yes, I can hear through the curtain of solitude.  Just like you can.

I still hope my phone doesn’t ring.  At least, if it does, I hope it is Patrick or someone from home on the other end.

And because everyone can’t get enough of Rebecca Black “Friday” parodies… Here is one about the subject at hand…