My Secret Hiding Place

Tomorrow is my last day of Radiology and the start to a week of glorious, glorious vacation.  I’m kind of excited because that means I finally get to stop asking people if it is okay if I watch them do their jobs.  Plus, we are going to New York, so everything has to be awesome.

It is hard to find someone to watch do their job.  Especially when there are at least 4 other elective students floating around.  I have counted.

On Tuesday, I tried to go to two other places before I realized where I could go actually learn stuff… PET/CT.  The secret world of diagnostic imaging.

First of all PET is awesome because it falls under the Nuc Med umbrella and thus is totally within my comfort zone.  Plus, it is one of the most modern imaging techniques on the go clinically, particularly in cancer care.

Most importantly, nobody else really knows about PET/CT.

It really is sad that they don’t.  I think most assume they get to see it if they go to do some Nuc Med or CT.  I don’t know.  It doesn’t come up a whole lot outside of oncology, so I get that not all people know about it.

But, to add to it, PET/CT isn’t included on the list of places we can have ticked off on our signature sheet.  I write it in.

And the scanner isn’t by the rest of the radiology department.  And it is behind a coded door, so you have to ring to get in.  And they don’t do PET scans every day.

I like that it is so mysterious because it is the one place I know there won’t be another learner in when I am on the prowl for work and having little luck.

I go down there and get let in and ask the radiologist if I can hang out and watch him read a few scans.  He says yes, but the first one won’t be done for an hour, so I can come back then, if I want.

If I want?  Of course I want.

I come to find out that I am one of the only elective students he has seen wander down there.

I tell him that PET/CT is my secret place when all the students are everywhere else.  That it isn’t on the list.  He tells me to keep it my little secret.  That way he can continue to have peace and quiet (and get other work done).

I like that I have my secret hiding place option.  It feels so stealthy and spy like.

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Learning in Ultrasound: A Person is a Person…

I can’t believe how fast February flew by.  It is Medical Monday again, which means time to link up with some other lovely medically affiliated blogs.  Check them out at the link below.

As you may know, I am on a radiology rotation.

A few weeks ago, I decided it was time I go see some ultrasound imaging.  Other aspects of imaging are more comfortable for me (especially Nuc Med for obvious reasons), but ultrasound is my black box, so I figured learning is good.  So, I am doing ultrasound at the hospital where I usually work.  Lots of livers and thyroids and kidneys.

Then, up on the screen pops up a perfect looking 8 week embryo.  Cool, I think to myself, that might be my kid in another four weeks.

Image from babycenter.com.

I then remembered that all of the obstetrical ultrasounds are generally done at the children’s hospital unless there is someone in emerg.  I asked why this ultrasound was done at the hospital we were at.

Its for the TPU replied the fellow.

Termination of pregnancy unit.

My heart sank.

He said I could leave if I wanted to.  But really, this is part of my learning.  Part of life in a hospital and in this world.

I watched him read four ultrasounds of perfect little embryos between 6 and 11 weeks all with heartbeats and the works.  Perfect little embryos that might have otherwise grown up, although it is tough to say for sure because bad stuff happens.

I went home and cried to Patrick because it seemed so sad and so unfair that these babies had to die when maybe they wouldn’t.  It seemed so unfair that so many women want babies so badly and yet here are people who for whatever reason or circumstance don’t or can’t want their own.

Just over a week later, after losing my own baby, Elim, I sat in that department again.

Yet again, I saw babies getting their photo taken to confirm that they were indeed alive (because the procedure is different if they are alive or dead).  I saw one person who had terminated pregnancies 6 times.

I had an overwhelming urge to go in and yell at these people.  To tell them that I am here, working and trying to piece together what is left of my sanity because my baby died before it would have even been very visible on an ultrasound.  That I really wanted that baby.  That it isn’t fair that they get to choose, but I can’t.  To ask a big huge why.

But, I didn’t.

Because that isn’t fair of me (or very professional).

Their baby dying, my baby dying, really, it is all a loss.  Those kids are all with God now.  They all had potential.  They all died because they were made in a fallen world full of brokenness.

That mom may mourn the loss of her child like I do.  Everybody grieves differently.   Maybe not now, but maybe later.  I have heard of the struggles of moms who make that decision.  And maybe she won’t.  I can’t put myself entirely in her shoes.

We aren’t very good at putting ourselves in other people’s shoes.  We are, however, really good at trying to point out other people’s wrongs.

Image from chzbgr.com.

I’m not here to have the pro-choice or pro-life debate.  In fact, I don’t want to hear it because it is often hurtful, overdone and narrowminded on both sides of the coin.  Sin is sin.  Death is death.   Pain and anguish are universal.   We have free will.  That is all on that.

I read this blog post from The Lewis Note called “Why Miscarriage Matters When You’re Pro-Life.”   It was strangely timely based on the adventures of the last few weeks.  Check it out.

I read this post the night after my second day in the ultrasound department when I was really struggling with the value of life and how we see it as a society.

It rocked my world.  Because it is so true, especially in a Christian context, but I am sure it works for others as well.

I have already experienced both the good and the bad sides of this post.  Some people are really nice.  Other people aren’t.  And some nice people say stupid stuff (I sure do).

Thinking on how I responded to people who lost kids at the same point, I think I had empathy and sympathy for both.  I think I did place more value on the aborted baby.  I also think I had more sympathy for that child’s mother because there was action and potential.

Looking at scans, it is the same.  Already dead babies are already dead, so in a way, it seemed less sad than about to babies about to die.

That isn’t necessarily fair of me.

Both an electively aborted baby and a spontaneously aborted baby were both alive at one point and had potential and value.

And then, there is our approach to the mothers and fathers.

Don’t forget the fathers.  Many people do.

Everyone needs love.  It doesn’t matter how voluntary a loss was, it doesn’t matter how old the child was (although this does often impact they way people can grieve and what is considered “acceptable”).  You need people willing to live the grief with you.  To sit it out with you because that is what you might need, even when it is uncomfortable (just like sitting through scans that are upsetting helps us to learn and grow in a different way).

If you claim to care about a person, to care about life, then you should stand by the mourning no matter what they are mourning and no matter how long that what was alive.  If you want some practical suggestions and examples, check out that post.  I am the first person to admit that I tend to project my feelings on others, so if I think something would weird me out, I tend to avoid doing that for someone else or letting someone do it for me.  I’ve learned that I am often wrong and my assumptions were totally incorrect.  If you aren’t sure how to help or love someone where they are at, ask.

I guess I’m learning more than I anticipated on this radiology rotation.

How this elective reminds me of grade school

Do you remember in grade school when you needed to have your tests signed by your parents and then bring them back to your teacher to prove that your parents saw them.

I sure do.

I very seldom had a test I cared about my parents seeing because it was bad.  In fact, I can remember most of my bad grades… Telling time in grade 1 (who needs clocks when you have digital watches), some math test in grade 3 and that is all I recall.  I remember not doing as well as I liked in grade 10 and 11 math and there was this one terrible imaging test in Nuc Med, but it isn’t like anyone cared if Mom and Dad saw those.

I am now an adult and not even a Med Student and yet I am kind of reliving that experience.  You see, I have done rotation where I have had to get evaluations done after shifts and get them signed.  That is one thing.  But right now, I literally have a sheet that is for me to get signed saying where I spent time during my radiology rotation.

The radiologists point out that it is like signing their kids’ math tests.

I am an adult.  I think I can self-govern where I go.  I do it most of the rest of time.

I get that it is partly for evaluation purposes.  Then the evaluator can say where I spent time and regurgitate any comments people leave.

Between the wandering asking if I can basically watch people do their job and the getting signatures, I feel like I am back to the job shadowing I did in Med 1 and 2 (and my radiology and pathology electives in Med 4).  I am learning, but it is draining trying to find something to do each day and feeling like I am more of a hinderance.  Especially after being pretty independent in most other rotations.

Such is life.

Today, I had a conversation that if you can still like radiology after doing this sort of elective, you could probably deal with being a radiologist.  I am by no means belittling their jobs.  It is hard stuff to do.  But, I get it.  If I can handle sitting for 8 hours watching someone do it and not want to die every minute, then I might be able to do it too.

I am still glad that I won’t have to do that exact job.  But I am glad that I get to deal with lots of imaging.

For now, I get my signatures.  And feel very inconsequential to the functioning of my service.  In fact, if I wasn’t there, the only person who would notice is the person checking the signatures.

I also get lunch and get to even take breaks sometimes.  I leave every day by 5.  Kind of like grade school.  Except my homework consists of things like research projects and physics.

Radi-what?

Today, I met Radiology again.  We meet daily on most of my rotations, but for the next month, we will be spending some quality time together.

It is new rotation day.  And my new rotation of the month four weeks is Radiology.

And just to clarify, in case you, like many people in my life, are thinking “That’s great, your home service,” the answer is no.  My home service is Radiation Oncology, not Radiology.  They are commonly confused.  Radiology takes pictures and uses imaging to take biopsies or put in certain devices.  Radiation Oncology treats cancers with radiation.

I have done Radiology rotations before.  I did job shadowing as a med student, then a full week in a summer med student program and two weeks of selective in fourth year med school and now this four week stint.  I have a whole degree in Nuclear Medicine.  A degree.

It is important stuff.  Seriously, without being able to read images and without the help of Radiologists being a cancer specialist, especially a Radiation Oncologist would be pretty freaking rough.

That being said, it isn’t easy to teach.  A lot comes from seeing the normal stuff over and over and over again.

And I have a ton I need to learn.

The thing is with Radiology rotations is that they are different from you usual clinics, consult or floor services.  You basically watch and listen to people do their jobs.  Sometimes, you get to try to do it too, but really, you are generally a bystander.  Because nobody wants someone random reading their CT scan without assistance.

Image from diagnosticimaging.com.

Because much of the day is watching people do their jobs, it requires consumption of mass amounts of coffee.  At least it did when I was a med student.  I am sure it will again.

Also, because it is a lot of watching people do their jobs, it is a lot of being told “Why don’t you go read for a bit and we can review the cases together later?” or “It is just boring stuff now, so you can go.”  And I get it.  I wouldn’t enjoy someone hovering and I wouldn’t want to feel like I was boring someone.  But, that is what I need to do to learn.

The good thing is that I have four weeks and lots of different things that I want to see and do.  Hopefully, I will accomplish it.  Plus, I can always go do some Nuc Med to make myself feel better inside from time to time (how often do you hear that phrase?).

That being said, it does also make for some excellent hours.

Tomato-Tomato: Answering some questions of distinction from the world of medicine.

Image from mentalfloss.com.

“You say tomato, I say tomato.”

You know the saying.  So, did my delightful teacher in Nuc Med, Debbie.  Except when she said the saying she pronounced tomato identically both times.

It cracked us up.

In life there are some things that sound the same but are different, some that look the same but are different and some that are indeed the same, but sound different.

Confused yet?

I have been asked a few awesome questions about some medicine-ish sorts of things by my readers and patients and family and have decided to answer some of them now.  These are answers to some of the “what is the difference between” sorts of questions.

Question 1: What is the difference between a ward clerk and a clinical clerk?

A ward clerk is the lovely person who takes care of all of the administrative things on the hospital ward.  They are the sunny face that directs people to rooms, answers phones and keeps the place organized.  They get paid for this job.  A clinical clerk, also known as a senior medical student is someone who is in their last couple of years of med school and is rotating through the hospital learning in a hands on sense how to be a doctor.  They are different from residents or interns.  They are NOT doctors (yet).

Question 2: What is the difference between an intern and a resident?

Not much and yet a fair bit.  An intern is a first year resident.  All residents are doctors.  They are doing training so that they can practice independently.  It is like another gradation of training.  You can’t just get a job working as a doctor out of medical school.  You get a job working as a resident.  In many places, there is a first year of “rotating internship” meaning the first year resident has to do rotations in a number of specialties of medicine to get well rounded before focusing on one area of medicine.  That is kind of what I am doing now.  Sometimes people say interns are off-service first year residents.  First year residents and fifth year residents are very different in that the level of training is obviously different.  You learn more as time goes on.

If I didn’t hate graphic t-shirts, I would need this shirt. Image from zazzle.com.

Question 3:  What is the difference between medical and radiation oncology?

Both are oncologists (although most people only consider their medical oncologist an “oncologist”).  Medical oncologists are doctors specialized in giving systemic treatments for cancer, like chemotherapy and hormone therapy.  Their background is internal medicine.  Radiation oncologists (not to be confused with radiologists) are doctors specialized in using radiation to treat cancers, often in a more localized fashion.  One is not better than the other.  The medical, radiation and surgical oncologists all work together to provide cancer care.  Sometimes for one cancer, it responds better to one thing and not another.  Others need all three modalities.  It depends on the cancer.

Question 4:  What is the difference between radiation oncology and radiology?

There were people in my med school class who I am pretty sure thought up to the day we graduated I was going into radiology.  Because they are clearly the same thing.  They are not, although back in the day, they were.  Then a lot more oncology started happening and things got more specialized and they branched off of each other back in the 50s and 60s.  Radiology is a field in which you read diagnostic imaging (CTs, MRIs etc).  Interventional radiology is a subspecialty of radiology in which you use radiologic imaging to do some surgical procedures, like putting in chemo lines and special drains.  Radiation oncology is a field in which you treat cancers with radiation.

Question 5: What is the difference between Hospice and Palliative Care?

At surface, there isn’t a major difference.  Often, the two are grouped together.  Hospice is a type of Palliative Medicine.  Palliative comes from the word pallium, meaning to cloak or comfort.  Pretty beautiful term, if you ask me.  Palliative medicine is a field of medicine in which you provide pain and symptom management, generally to people with life threatening illness.  Being cared for by palliative medicine does not mean death is imminent, but that cure is unlikely and comfort is important.  Palliative medicine is all about quality of life.  In a hospital, there may be a palliative care unit – an inpatient unit that provides comfort care.  In the community, there may be a Hospice house or organization.  Hospice is a type of palliative medicine and a sort of philosophy.  It is home-based palliative care.  Meaning, people are supported at home through outreach teams or they can go and live in a hospice house, which is a home like setting providing palliative supports.  Often, a palliative care unit is a bit more hospital like and can provide a bit more hospital-type supports compared to a hospice house, which is basically a home away from home.

 Question 6: What is the difference between the short white coat and the long white coat?

Good question.  My first guess would be the amount of white fabric available to get dirty (I am not a fan of white coats).  Apparently it varies from school to school.  Where I came from, the short white coat was a symbol of you not being in your clinical years.  You wore it to shadow, to clinical skills and such.  It was a sign of being a rookie.  Once you hit clerkship, you could wear the long one.  In some other places, all medical students go short.  I have no clue.  I guess it depends where you are.

This image, taken from an article in boston.com demonstrates the different styles and people wearing white coats and how although long white coats are traditionally associated with attending physicians and big accomplishments, it does not mean only attendings wear them and the reverse is true of the short white coat. Bet you can’t tell who is who.

Question 7:  What is the difference between an allergy and a sensitivity?

An allergy is an immune response.  A sensitivity is kind of like a nasty side effect or irritation.  People claim they are allergic to all sorts of things they are not.  If you vomited or itched or got constipated on morphine, you probably had side effects and may have a sensitivity.   If you develop hives, intractable vomiting or difficulty breathing, then it is an allergy.

Question 8: What is the difference between nuclear medicine and radiology?

Nuclear medicine is awesome.  That is the clear difference.  Seriously though, nuclear medicine involves imaging radioactive tracers as they behave within someone’s body (physiologic imaging).  For instance a bone scan images a tracer that acts like calcium and binds to bone.  Areas of fracture, wear and tear, infection or cancer appear brighter because that bone is turning over more quickly.  Radiology generally involves external radiation projected onto a film through the body.  It images anatomy only for the most part.   Think x-ray.

Upper left is a bone scan of a hand with a fracture of several carpal bones (with pins in place). Upper right is an x-ray of the same hand). The bottom left is an example of a fusion image with the two modalities showing how activity can be localized to an anatomic site.  Image from HERMESmedical.com.

There you go.  Eight awesome questions I get relatively often about things that seem very different or kind of the same.  Let me know if there are more questions.  Or more answers.  Either are delightful.

You just wouldn’t believe, you just wouldn’t even know…

Some friends of mine and I have this inside joke saying “You just wouldn’t believe, you just wouldn’t even know.”  Sounds normal enough.

You see, we were on a camping trip (at a campground in our own city) when a couple of our other friends stopped by.  One of them went into the tent to find something without a flashlight and started screaming, “It’s so dark in here, you just wouldn’t even believe, you just wouldn’t know.”  It was hilarious.  Partly because we all could believe, partly because of who said it and partly because of how loudly the person was screaming this at 1 in the morning in a family campground.

From then on, whenever something obvious or not so obvious would happen, one of us would sometimes state a “you just wouldn’t believe, you just wouldn’t even know.”  This could be in reference to something as simple as darkness or as huge as something epic happening in our day.

We haven’t said it a whole lot lately, but something in physics class made me think of it today (clearly, looking back on the past two months , some of my best Thursday thoughts come out of physics class – see here and here).

You see, we were learning about treatment planning, namely the physics behind CT scanners and talking about how quickly the x-ray source and detector can spin around the patient.  We were saying how it would be cool in theory if the casing for the scanners was clear, so you could see it (the problem being this would totally freak patients out).  They are fast “like you just wouldn’t even believe, you just wouldn’t even know!” We then watched this video to illustrate.watch?v=CWnjqeB7Mk8

The even crazier part to us (beyond how fast that thing spins at top speed) is that 50,000 other people in the world have watched this video.  I know compared to some other videos on the site (like Gangam style that has 500 million hits – we checked) it isn’t much, but for a weird CT related nerd video, that is huge.  “Like, you wouldn’t even believe, you just wouldn’t even know” kind of huge.

Other big win from physics today is that I remembered to bring my coat, so I didn’t freeze completely.  Oh, and because I had half day this afternoon and there was a clinic the other residents didn’t want to go to in the morning I got to go to clinic and half day and someone else covered the floor calls. That made me happy “like you wouldn’t even believe, you just wouldn’t know”!

There are other nerds out there.  I believe and I know.  But it is still fun to say that other phrase!

Don’t Shoot The Messenger

As the junior resident on my surgical team, I am often the bearer of everything related to the inpatient floors, which includes much bad news and a number of messages that are not taken to kindly.

I do what I can to manage things on my own, but often times, I get sent on little missions (or big missions) from the staff or seniors to ask for scans, sort out orders and do all sorts of other things.  That is my job.  That is how I learn about how to manage the more complicated things.

Sometimes, though I get sent to ask for things that are a touch on the outlandish side.  Or difficult to do.  Or just plain disliked.  And then I am the one who gets to hear and bear the brunt of the reaction.

Take today, for instance.  I was told to go order a CT scan for my septic post-op patient with a known history of Crohn’s.  Seems simple enough.  Problem was, this patient already had 2 CTs in the last month (and one was only a few days ago).  The team agreed it was a tough call, but we just had to be sure there was nothing there we needed to drain or operate on.  I, of course, got to go to radiology to ask for the scan.  And of course, they didn’t want to do it.  Because the interval was so short.  And the indications, though good, were limited, as the patient has had so many prior surgeries and had identified potential sources of infection on the last scan (fistulae and such from underlying disease).  I got a lecture explaining radiation risks, and resources and the effective use of scans.  I know these things.  But, I was stuck.  I already had questioned it.  And it didn’t work out.  In the end, I had to get my senior to talk to radiology.  The scan did get done.  It didn’t show anything.

In another instance, I was told that another unstable patient did not need to be transferred to intensive care unless vitals did x, y and z.  I did agree with this, it only made sense.  They were stable, but happened to have a giant clot in an extremity and a tiny one in a lung.  I had the misfortune of reporting this to the unit staff.  They are extremely experienced and very helpful 9 times out of 10.  But this time, they were extremely busy and pushing for me to get the patient transferred.  I couldn’t do that.  It wasn’t my place.  And it wasn’t necessary.  I heard the brunt of the complaints.  And I heard them discussing it (and me) in the next room.

Then, there are the really not warranted reactions (at least not on the grounds of my action alone).  The people who flip out at me for coming to assess them on morning rounds, for instance.  Or the resident that gets angry when they get paged for a reasonable consult.

Yes, there may be other things going on to cause their reactions.  But that still doesn’t make it a completely acceptable way to respond to others.

I understand that the natural human reaction in upsetting circumstances is to vent or get angry.  And I understand that I am still learning and sometimes do some REALLY stupid things (take when I cancelled and reordered different doses of the same med three times between discussions with the team and then pharmacy and then nursing).  I get frustrated with me too.  And that is a way of learning.

But sometimes, I have to do things, not because I want to or even because I think it is best, but because it is what I am being required to do (whether it be for medical/legal or team hierarchy reasons).  I appreciate the learning opportunities and hearing opinions, but there is no good reason to shoot the messenger.  Even if she is the easiest target and the one who appears most at fault.

These experiences will help me as things move on.  I will remember and maybe make different choices.  And maybe stand up for what I know and believe to be right or true a bit more.  But also, I will try to not create situations in which other people will want to shoot the messenger unnecessarily.  And maybe I will not shoot the messenger so much myself.  Because some of these behaviors are a cycle, not just learning or human frustration.  By stopping the cycle, maybe I will save someone the angst of being talked to for things they can’t change.

Sometimes, people have good reasons for doing things you see as wrong or stupid.  Your reaction may be warranted.  In fact, in my first two examples, the reactions were, at least somewhat warranted.   There were things that could have been changed to make things make more sense and the actions may not have been the best.  I get that.  Sometimes, you have to tell someone and get upset.

But, sometimes, more thought needs to go into who and why things are happening.  And who or why to be angry.

I guess it all comes down to not shooting the messenger.  Unless, of course, they are the source of the message that could otherwise be improved.

The arrow sign

Clerkship is coming to a close… Last day is tomorrow (EEP!).

That means in just a couple short months, I will be an intern and a resident and then eventually (a long, long time from now) I will be an attending.  And with all this comes more responsibility.  Ack.

I love responsibility.  I thrive upon it in a sick sort of way.

Medicine has an interesting way of both shoving us in over our heads to make us learn and yet sheltering us because too much responsibility too soon can be a dangerous thing.  So, we basically do graduated on the job training.  Slowly build our confidence and the degree to which we manage and diagnose.  Sometimes, even when we feel hung out to dry, there seem to be hints of help, sometimes accidently left out there or bits that we learn to feed off of.

One of my favorite “hints” is the “arrow sign.”  This is the miraculous thing that appears on some x-rays and CT scans placed by some much wiser (though sometimes not) that generally points to the abnormality (or points to you looking like an idiot when you identify it as an abnormality).  Generally, the arrow sign is a partial get out of jail free card left there by someone.  It points to one or more of the findings on the scan and screams “look right here!”  Though it may not show everything, it at least points (ha ha) you in the right direction.

Arrow sign pointing out an epidural hematoma and a "swirl sign," which is a hypodense area representing actively extravasating unclotted blood. Image via radiologyinthai.blogspot.com.

While on this radiology rotation, arrow signs are few and far between, because I am often one of the first ones to see the film.  I miss things.  More often than I would like to admit, though I am getting better.  I have left a few of my own arrow signs (some of which may inadvertently mislead other clerks… Whoops).  But this is how you learn.  Practice.  Even with the arrow signs.  Then, you get better and you learn where the arrows should go.  You can function without the arrows (even if you like them).

You don't really need the arrow sign to help you pick up on these fractures. Image via radiology.casereports.net.

Another good “hint” that becomes a bit of a survival mechanism for clerks is reading around your patient… In their old charts, the ER record (this doesn’t work as well when they are new and haven’t ben seen by anyone else).  There, you can sometimes find details that get missed/forgotten on history and also past physical exam findings and labs.  Sounds like common sense.  But, really, if you know the person has a grade I systolic ejection murmur (translation: super quiet murmur)… You can listen more closely for it.  I know, you should listen all the time.  But sometimes, the extra point of focus is useful.  Plus, then you can tell if it is unchanged from previous.  Or you can hear your first grade I murmur.  I think this is a valuable tactic, so long as you use discretion.  Old H&Ps can contain mistakes.  So, verify your info with the patient, confirm your own exam findings… Just plain do your work.  They are a resource, not a replacement.  When you see people with more undifferentiated problems, this is not always an option, but the practice with those who you have all kinds of information helps you to learn the process and be more cautious with it.

You may never hear a murmur in this guy... No matter how many of you try. Image via medicalcareersite.com

My last “hint” that the world of medicine has fed me over the years is the “why don’t you examine this and tell me what you find.”  In a normal, healthy person, odds are its nothing.  But they aren’t the people you get told to do that to.  Usually, it is someone who is unwell and who has a finding.  And the person asking likely knows what it is.  So, go in expecting to find something.  Especially if you know they have a process that produces a finding.  Other side to that… If don’t note something abnormal… Don’t make it up.  Because they are probably testing to see if you will lie.  Just do a good exam.  Anticipate the common things.  Even while you are breaking out in a cold sweat because you don’t want to look stunned for the tenth time this week with everyone looking on expectantly.

I think sometimes in life, just like in medicine (because clearly medicine is not life), we get signs pointing us in the right direction.  Things just fall into place.  We know based on surrounding circumstances that we are supposed to take a designated action.  We quite literally get shoved that way.  The apartment that Patrick and I have been blessed with (blessed is used both literally and sarcastically… did I mention we are STILL under construction?) while living in here was one of two I went to see that day.  One was a hole.  This one was one of the only places that answered their phone and was in our price range.  It fell into our laps.

Other times, though, we go around searching for an arrow sign.  We just want God to draw a nice clear arrow in the sky pointing us in the direction He would like us to take.  A nice spiritual hint.  An obvious track to go on.  And we don’t get it.

Just like in medicine, we have graduated responsibility.  As kids, our parents make our decisions, but as we grow, we are left to make more of the choices.  They redirect us where appropriate and we learn.  God lets us make mistakes and if we really pay attention to Him, He gives us hints.  Maybe a specific system to examine.  We know the theory.  He gave us a whole textbook.  We just need to apply it.  We need to seek out the hints to help us along.  God gives arrow signs sometimes, or a specific system or at least a history… We just need to pay attention long enough to get the hint.  And apply what we have learned to do the right thing.  And it is tough.  But it is possible.

Sometimes, I feel like life (and medicine) would be easier if we always had arrow signs.  If we just knew where to look or what to do.  And sometimes we do.  Sometimes God slaps us in the face with how obvious what we should be doing truly is.  Not all of the time, but sometimes.    But really, if everything were dead obvious it would be boring.  It would be safe, but we wouldn’t have choice.  There wouldn’t be the rush of making the right call or the same commitment to God.  So, I am grateful that we need to learn to look for the signs without the obvious arrows.  Even if I don’t always like it so much.

Food and flannel

The other night we were hanging out with friends and Patrick re-iterated what he truly believes are the ways to my heart… Food and flannel.

Sounds ridiculous, no?  But honestly, there is a good bit of truth to this.

I have to feel fabrics before I buy them.  I seriously manhandle them in the store.  There are some I just can’t handle.  Sensory issues.  I only like fleece and flannel and jersey cotton to sleep in.  Yes, first world problems for sure.

As I have said here a million times… I love food!  And I love to cook, especially when I get off work with time to make a decent meal and we have the ingredients in the house.  In the past week, I have had a chance to make a few concoctions thanks to the beauty of a radiology rotation with no call and where I see images of all kinds of things that would impair people’s eating abilities.  I guess seeing people’s insides that cause them to not eat makes me more grateful for my eating abilities.  At least that is how I will rationalize it.

So, a few recipes…

Whole Wheat Tea Biscuits

This is a pretty traditional recipe… Except as usual, we only have whole wheat flour, so everything ends up with a bit of distinct whole wheaty twang.  Not always optimal.  So, I added some extra milk and butter to these to minimize dryness.  It seemed to work.

2 cups whole wheat flour
4 teaspoons baking powder
½ cup butter
¾ cup milk
¼ teaspoon salt
Preheat oven to 400 degrees. 
  • Combine the dry ingredients and butter and mix until it is a crumb mixture.  Then, add the milk and mix until the dough is moist and soft.
  • Roll the dough out to approximately 1 inch (2.5cm) thickness and cut out circles (I did this by hand for a diameter of about 5cm.
  • Allow to set for 5 minutes prior to baking.
  • Bake for 12-15 minutes.

Eggplant appetizers

I have developed a new found love for eggplant.  This is one of my favorite eggplant based recipes.

Two to three chopped tomatoes
1 large eggplant, peeled and cut into 1-2cm thick slices
Olive oil
Grated cheddar or mozzarella cheese
Oregano
  • Preheat the oven for 450 degrees.
  • Pre-soak the eggplant slices in cold salt water for at least ½ hour prior to cooking.  Drain and dry the eggplant.
  • Brush the surfaces of the eggplant with olive oil.
  • Place chopped tomatoes on each slice of eggplant and sprinkle with cheese and oregano.
  • Bake on a well greased baking sheet or broiler pan for 20 minutes.
  • Serve immediately.

Avocado-salmon sandwich

This is not a profound recipe by any means, but it made me happy.  We had leftover smoked salmon from the night before, so it needed to be eaten and I had read previously that avocado is great on toast, so why not combine them.

The recipe is simply toast with one side covered in sliced avocado and then the smoked salmon.   It was amazingly good.  I may try to make something similar on baguettes for a potluck sometime.

Incidentaloma… One of my favourite words, not my favourite finding.

An incidental finding.

An undiagnosed condition discovered unintentionally that is unrelated to the current medical or psychiatric condition being investigated and/or treated.

Kind of like an accidental finding, but it sounds better.

When I was in Nuc Med, one of my favorite words in medical terminology was “incidentaloma.”   A tumor found by coincidence.  It just struck me funny.  Just like saying “tumour” like Arnold Schwarzenegger.  I even did a scan that turned up an incidentaloma… A parathyroid scan that ended up detecting a right upper outer breast lesion.  That turned out after further assessment to be an early breast cancer.  Pretty exciting stuff for me as an undergrad.  It merited a case write-up.  Not quite as exciting for the patient, but at least it was detected early.

Adrenal incidentaloma. To be further assessed with a triple phase CT. And hopefully turn out to be benign. Image via Disease Disease.

Reading watching the radiologists and residents read scans over the past week has had me thinking about that.  Mainly because there are incidental findings every day.  Most are inconsequential, as you would expect.  Weird little benign growths or malformations that the person wandering around has no idea about and that will likely never give any trouble.  But some are more consequential… More significant.

When one of these little incidental things is found.  One that may be one of several options, the person is often referred for more tests.  Or consultations.  A hypoattenuating area in the liver may be a cyst or a mass or a hemangioma.  An ultrasound can help or a triple phase CT.  Lots of people have chunky adrenal glands… Most are benign, but it could be disease… Triple phase CT again.  Funny nodule in the lung… Let’s rescan in another few months to check for change.  These findings lead to more tests, more questions and more findings.  Often, the diagnosis is cleared up with only minimally more distress for the patient and somewhat more radiation exposure.

Sometimes the little incidental things aren’t so little.  A man with abdominal pain in the ER gets a CT to rule out appendicitis or diverticular disease and he ends up having a very large almost obstructing bowel cancer.  A woman with back pain who turns out to have lesions all over her spine that are likely spread from a cancer.  These lead not only to further tests, but life altering diagnoses.

Suddenly, incidentalomas are not so fun anymore.

I love that in medicine, we have the ability to pick up on things, sometimes early enough to prevent serious disease or at least be able to give some sort of explanation.  But, sometimes being able to see so much isn’t good.  How many people do we see with subtle “likely nothing” abnormalities that get scanned repeatedly, slowly increasing their risk for radiation induced cancers and elevating stress levels, just to say it is nothing.

Surprise! A pelvic kidney. Does it matter? Not usually. But its cool. Image via imageconsult.com

Then comes the question of how much do you tell people?  I am a big pusher of the whole people should be well informed about their health care and their body.  But, do you tell them about the one degenerative asymptomatic disc in their back, the benign nodes in their abdomen that may someday become something, but probably won’t, the cyst in their kidney?  I lean towards yes… But then I think about what difference does that make?  Will the person understand?  Is it really for me to decide?

I don’t have the answers.  I do think it is an individual’s choice how much they want to know and how much they will understand.

Our life is full of incidental findings as well.  Generally, we wander around oblivious to outside circumstances that may impact us.  But sometimes we hear things or learn of things that we probably shouldn’t or wouldn’t have if we weren’t out searching for something else.  Because, realistically, we can’t know everything… Only God does.

But, when we find out one of those odd details, they can change the course we are on… Sometimes for the better, others for the worse… And, at times, they change nothing.  We meet people who were unanticipated, who we did not think were actually going to be important in our lives and they turn out to be glaringly important to us.  We find flaws in ourselves that we never noticed previously that can be corrected.

Incidental findings are the surprises and bumps in the road within our bodies.  Often nothing but a pain in the neck (figuratively) when you have a real pain elsewhere.  But, they can distract us from finding the real underlying problem because they are glaringly obvious in a particular image or because they are more easily assessed.

Just like incidental findings, the incidental things in our lives also can play that game.  A minor surprise or setback can take presidence over the bigger issues at hand.  I know that I am currently dealing with every little thing as opposed to the bigger LMCC because the little things are more apparent and easier to tackle.  I guess we need to remember to manage active problems and assess the minor or less urgent things later.  Easier said than done.