Worn Out

One thing about being a student of medicine, a doctor anyway, I suppose others in my profession (nurses, pharmacists, etc) are similarly afflicted, you are subjected to rigourous testing...and more testing...and more testing. I think now they are requiring that we docs retest every 10 years, after initial certification by our boards. It's a pain, but I think it's appropriate, I've seen far to many "old farts" already who prescribe outdated treatments and in some cases I've seen some who have no right to practice anymore...maybe they never did...I'm speaking of the doctors whose methods were NEVER accepted. Luckily of the latter group I've only seen one doc practicing like that, I was new to the profession, but I still turned his butt in to the medical board...in some cases he was ignorant, which I can understand, in other cases he was purposefully unethical and harmful, which I can't. Not to put myself on a pedestool, I'm not perfect and never will be, and that's why I think repeatedly testing us is a good thing even if it is a huge pain in the neck. I've been studying for this test for two months now, on average 2-3 hours a day on top of what I do for work has been punishing. I don't feel like I see my family much and I feel like I'm stressing them in leaning on them to take care of my son. I'm four days away and the anticipated relief of stress is so sweet I can taste it. As a side note, I remember writing on here in a fairly depressed attitude about doing sub-par on my introduction test to the residency program. I just got the results of my second test (they have us repeat it yearly until the actual exam at the end of our third year). This time I did much better and passed with flying colors, it's really tempting to stop studying now that I feel I've "caught up", but I'll try to keep it up and make my chances of failing the test miniscule (if I do, then I won't have to pay 5 grand to a test-prep program like many of my peers do before taking that bear of a test)...I guess we'll see how that works out. Well time to go to work, my ED shift will be starting in 30. I'm working the 4p-2a shift (as I have been for the past week), it's a fun time, but all things considered it's all starting to weigh on me. It's funny that I used to fear the ED, now some of the things I used to reel away from are some of the things I look foreward to (trauma's, laceration repairs, difficulty breathing, etc.) It's crazy how a year of residency can change things.

Newbie Doc

Bad News

I can't think of a more insidious, evil than cancer.  Rarely, is it's presence not tragic and unexpected.  It creeps in during the dark of the night and steals your loved ones away.  Is it me or does it always feel like the jack-asses of this world could smoke 50 packs a day of cigarettes from the age of 2 and get away with a clean chest x-ray at 90, while those rare kind souls who the world is blessed with to a much lesser degree are taken from us in car wrecks, cancer, and all kinds of random tragic events that Edgar Allen Poe couldn't even think up.  One of my good friends in residency was just diagnosed with a rare form of breast cancer...if you spend long in medicine you'll learn that the words "rare" and "interesting" are not words that you want associated with your disease.  Yet again it couldn't have happened to a more undeserving person.  Why can't the child abusers of this world be struck by these things instead of good people, like my friend Mindy?

I haven't read the whole bible, probably not close to half and it's probably a huge hypocrisy that I'm speaking of it, but there's one book that I've read and obsessed over since I was a little kid, The book of Job. Why would God put someone through such horrible things?  In the end, I finally realized the message of the book (the message to me anyway) isn't that God has a plan (which I believe he does), the message is that God is too complex for you to understand and trying to see or figure out the plan is like an ant trying to read advanced calculus, it's too ridiculous to even attempt.  That book's message to me is to quit looking for the plan and to try and walk the road he lays down directly in front of you, that in itself is hard enough.  In a way, it's relieving to give up control and let him steer...in the back of my mind I ask myself, "Even if he steers you off a cliff?"...and somehow I'm still comforted...I guess, at the very least, I'm not driving off the cliff by myself. (which could happen easy enough if you've ever seen me drive)

Newbie Doc

Uproot

It's crazy to say that you can develop close and good friends within a years time or that you can get attached to a place in the span of 12 months, but as I was walking through my hospital being faced with a new job opportunity and simultaneously the idea of leaving this place in another year and a half, I was suddenly hit with a twinge of sadness deep in my chest.  I think that whether it's the 18 years of living at home, the four years of college, or even 1 year of residency, when you're put through the stress of personal growth your soul puts down some roots and you take up a little bit of everything around you in your heart.  It's not home to me, but to the doctor in me it's where one day I'll say I grew up.

Newbie Doc

A Bad Situation

Just a quick post about a bad situation. A 16 year old male came into our ED the other night with an osteosarcoma of his femer head. An osteosarcoma is a bone cancer that you don't want to mess around with. Complicating this is that he is an illegal from Mexico. He was diagnosed and treated there, when medical complications arose the mother lost faith in her country's doctors and crossed the border to the US, where a certain hospital took her son in. The hospital offered to pay for his medical treatment for free. As treatment progressed it became understood that the only way to save this young man was to do a hip disarticulation, basically cut out all of the tumor and amputate the leg. Since a large portion of the hip would have to be removed, getting even a fake leg would likely be impossible, this boy decided he would rather die. After lengthy discussions with the boy and mother, they left the hospital on pain medication, before leaving they were warned that they would not get the same generous offer upon returning and were unlikely to find it elsewhere. I meet him two months later when his pain medication is no longer controlling his pain. They are now requesting that we move ahead with the surgery that the other hospital purposed. I call the higher ups to request admission...admission denied. Per congressional law I'm alotted the power to stabilize any acutely life threatening problems and discharge the patient after that is done. We run basic labs and find no such immediately "life threatening" problems. I sit with the mother and tell her as she's crying that we can't help her son. I offer what little I can, a script for improved pain management and advice to return to Mexico as soon as she possibly can (which she has the power to - I asked - but which she is extremely resistive). I sat there in silence for a long time...what could I have done differently? I don't know. I've thought about this alot and I can come up with two arguments one very logical, cold, and practical and the other much more humanistic, either way I can't really wrap my head around it yet...the factors that led to that situation are just so complex, so horribly muddled, that I can't even process it. Any takers? Did I do the wrong thing? Part of me says I did, despite having done it "by the book", part of me says I didn't. That mother thinks we did. Do you?

My Belly Hurts

So the night after writing "moon walking" a friend of mine who is now one of the head residents, a "chief", calls me wanting to know specifics on a kid I treated as an intern, she is giving a lecture for morning report (doctor's lectures to other docs). As she is retelling what she knows of this patient, a little cute girl, Emily, comes into my mind, she's sitting in bed with pink jammies telling me, "My belly hurts". She's one of those kids that you hope that you would have someday, cute and sharp as a button tack, she loved to play soccer, she was 4 or 5 at the time. She came in with abdominal pain and occasional headaches, we did a quick workup culminating in a endoscopy and colonoscopy by the gastroenterologist which showed an odd finding, as they scoped her the very mild stress of the procedure on the colon was causing bruises and hematomas (collections of blood). We didn't have a clue what was going on. Then, my golden weekend came and I left for home to ponder what was wrong with her wondering what they would have found when I returned but, when I did come back the attendings had discharged her to continue the work up for her problem in outpatient, as she was medically stable and not in danger.

As time went on, I'm ashamed to say she left my mind, this girl in pain that we couldn't help. Now a year later, my good friend, tells me that what had caused all this was hypertension (high blood pressure). I looked at and wrote down her blood pressures every damn day! The high blood pressure was causing the headaches and the bleeding and the stomach pains....and later as she went on over a YEAR undiagnosed and untreated it started to affect her vision...it started to affect how she thought...she eventually was so debilitated she no longer could play soccer. When she told me what had caused the pain, I cursed. When I asked how she was doing, my friend tried to soften the blow, but I looked up her records...and I know that if I'd just been better I could have caught it, such an easy catch...and yet it went undiagnosed for over a year, with high blood pressures documented at every visit, sick and well, just one doctor recognizing a single number was high could have changed her life. The problem lies in that childrens blood pressures are much lower than adults. An adult BP (blood pressure) is typically normal at 120/80...she had the misfortune of having a blood pressure too close to the adult normal, and as such she was overlooked until her BP got higher than the adult norm.

As I thought of that little girl sitting at home sick for a year, sitting out of games, and crying in pain, it really started to wear on me...her sight almost lost...I found myself crying on the way to work, this was only supposed to be a job!!! What kind of job hurts people when you screw up?!?! If I didn't realize the gravity of my job before, I do now, I don't even know if you should call it a job, it's something else entirely to me now. For every "moon walking" story, how many of these stories are slipping passed me quietly? Whenever I think of that girl, I feel a great regret and a mistake that I can't fix no matter how I try. I went to the computer people where I work and got the computer to recognize age and height specific blood pressures, it should be working within the month, within a month this kind of error won't be possible again...it doesn't seem enough. I don't care if I save hundreds kids from her fate with that fix...I didn't save her. I'm already thinking up more schemes to improve the system, but when I get down to it, I don't think I'm ever going to get rid of her skipping around in the back of my mind, weeks later it still stings when I think of her...when I think of my son, should he endure a similar fate. I've thought about calling the mother and apologizing but I shy away from it the second after...I come up with excuses (bla bla legal bull crap bla bla your not the only one to blame bla bla is the apology for you or her? bla bla bla)...I don't know if my cowardice will allow me...maybe in time, after I feel that I've in some way made up for it (if that ever happens)...I don't know...Whatever happens in the end my mind will work her memmory over till her rough stone in my stream of consciousness becomes smooth as a river rock but, regardless how I wear down the sharp edges, she's a part of me now and likely forever. Like I said, occasionally I find my feet on the moon but it doesn't take long till I find them slapped down to earth again, reciting my mantra, trying to clear the pain of my mistakes from my head, "I'll do better next time...I'll do better next time...I'll do better next time...God, Emily, I'm so sorry."

Newbie Doc

Moon Walking

I remember writing about how medicine and becomeing a doctor is discouraging. It's like your goal is journeying to the moon and you are so far away and every day is only a single step, it seems unobtainable. My thoughts concerning that goal over a year of being a "doctor" hasn't changed...you still take it a step at a time, each achievement you pat yourself on the back for and each failure you close your eyes and recite your mantra, "I'll do better next time". You keep telling yourself that every failure and every success just moves you one step closure to that goal that is so far away.

For the past 3 years I've been practicing my eye exam. To me it's a very hard thing to do, use that opthalmoscope. I've been using it almost daily for the past 3 years and I've finally gotten to a place where I can routinly see the vessels in the back of the eye. Some patients I still have a problem with and can't for some reason. Many of my collegues when I question about it say they don't even try...I myself have wondered why I keep it up. Well several months ago now I got a 14 year old male in the hospital with a horrible headache, he'd been into several emergency departments and urgent cares, all of which had treated him as a migraine and sent him home. I met him early in the morning, he had continued 10 out of 10 pain despite adequate pain management (which honestly is pretty typical of most teen migraines), however some things struck me different about this patient. His mom was histerical and insisting something was wrong with her son. Most mothers of teen migraines have seen it before and in the back of their mind, either know that the child is just having a migraine or in the case of most female teenage migraines know that the child is faking it (evidenced by the 17 year old female text messaging her boyfriend with a smile on her face saying that her headache is a 10 out of 10 pain level). What added to that was this was a stable family, I notice most males with migraines either have a strong family history or an unstable family/social environment. On top of that, he was complaining of symptoms that were very un-migraine, he said that his hands were balling up involuntarily.

When you suspect brain pathology (a mass or increased pressure) there are only a couple of things you can do. You can do a neuro exam, look at the backs of the eyes, and take picture of the brain with an MRI or CT. By far the quickest check is to look in the back of the eyes with the opthalmoscope, but I'm convinced not many doctors (even the experienced ones) can do this...(I've seen most just defer it and do one of the other tests or order an optho consult). But, I've been diligently practicing, so I dim the lights, focus the scope, and tell him to pick a point in the room and focus on it. I pull the scope up so we are centimeters from each other. My light coarses through his pupils and I see the back of his eye clear as day. I focus a bit more until the vessels are crisp in my vision and then I follow them to the source, the enterence of the vessels into the eye...I'm shocked...I see a glimpse of white...it's ussually red/pink/orange. I peer closer, he must feel like I'm going to jump inside his skull. There surounding the enterence of the eyes is a white puffy donut...papilledema, wow, after years of practicing it's finally paid off! In a second for free, I've identified the cause of this kids headache. He has increased pressure on his brain that is pushing on the backs of his eyes. I've done what a CT and MRI couldn't, I send him for an STAT opthomology consult to confirm my findings (Come on I'm practiced but I'm not at all confident)...they confirm my findings and he's sent for a lumbar puncture which removes the excess brain fluid, his headache is cured. Although time has passed from that moment, days have turned to weeks, and weeks to months, and during that time I've found myself still on that long journey still millions of miles away from my goal, in that one moment I was standing on the moon.

Newbie Doc

Winning the Oscar

One of the things I've been afraid of from the get go was having to be the leader. I've never been that kid. When I sit in class I sit in the middle of the room, least noticeable. When I played football I played the safety. When I'm in a group I never lead, I am the ever dependable guy with good ideas...it scares me being in the spot light, everyone following my choices, dealing with my mistakes. When I first committed back in college to becoming a doctor, it only occurred after the fact...after it was too late, that for me to be the doctor that I wanted to be, it would require me to make some major character changes. It was a fear I pushed to the back of my mind and I told myself I'd deal with it later. Well I'm dealing with it now. It was one thing to be the person in command when your the one in the room with all the medical knowledge, it's just default that everyone will be listening to you, in a way it's like a senior in high school is the default leader when placed in a group of freshman...that's not hard or scary for me. Here I am this month placed in a group of doctors similar to myself, some better doctors in every way than I am...and it falls to me to lead them...that is absolutely terrifying.

This last month I was one of the five ward seniors (head doctors overseeing the lesser experienced interns). Wards can be a scary place for any doctor, intern to attending. The place I work have complex patients and they can go down the tubes quick. As a senior I'm giving up that blanket of comfort, that while I'm the doctor, that there is a much more experienced person above me giving me direction when I need it. Gone is my ability to manage every little aspect of my patient's care, I have to entrust that to my interns and hope and pray I'm a good enough teacher, doctor, and leader that they will do no less than I (hopefully better).

That would be scary enough, but every 4th day as a senior you are called to be admit senior, where you have to take charge of not only the interns but the other seniors as well. A position that puts you nose to nose with the attendings, making calls they have to deal with, in effect ordering them around as well.

Well in short, I'm almost done with this month. I have two days left and what I have found is that when swarms of patients are incoming and you are called to lead, you either crumble on your poor confidence or you stow it and start tossing orders to get the job done. If you make a mistake you apologize to yourself, quietly...tell yourself to do better. You put on a different mask, it may not be you or even the person you want to be, but you do it to exude the confidence needed so that the people under you will follow the orders you hope to be right. The hesitance you can feel as an intern or as a person not wearing that mask gets shoved aside, if you are the one protecting the patients when the interns don't have the knowledge, the experience, or the confidence...then you take the knowledge you have in hand, the experience and the common sense you've scrapped together over a year and if you're like me and you don't have the confidence, for your patients sake, you damn well better win an oscar faking it.

I'm not done and I've got a lot to learn still wearing this "mask", but this has what's got me through so far and I've got my fingers triple crossed that its working.

Newbie Doc

Bode, Cute and Scary

Having a kid is great, seems like it just gets better and better, but I do get to see the flip side of that being a Pediatrician. I get to see children who've gotten sick and then get sicker and sicker in a slow spiral towards death, I've seen it rip families in half...actually that's the norm, it's not a few of the weaker families...most families I see with a child that is chronically or fatally ill ends up destroyed...not only that but each parent is in their own personal hell and it's hard to imagine how they get out of it. I love my son, but a part of me can't help but look at him in fear sometimes. Sometimes I'm really scared of how attached I am to him.  I know I'm attached to many other people and things in this world, but I never have gotten to see what removing those things does to a person, but I've seen what removing a child does to a parent and in that way my son sometimes scares me. 

Newbie Doc

Another Vaccine Rant

Both stories are mostly true. But one of these stories, indirectly hurt way more people than the other.





The truth is there are horrible stories that go with both vaccines and the diseases they protect against.  Guess what, we've done the research and far more horrible stories pop up when we don't vaccinate.  Ya it sucks, occasionally people ARE harmed by vaccines...but diseases ALWAYS harm people...ummm... that's why we call them diseases and not immune system calisthenics.

Which is more likely, hundreds of thousands of smart, well-intentioned doctors and scientists are in a giant conspiracy to make money and hurt people while doing it versus a few people are unusually and illogically polarized against something they don't fully understand (or understand at all).

Newbie Doc

Death, Taxes, and Ignorance

I remember when the last election came out and Palin went on a rant about "death panels". Honestly, I haven't read exactly what that specific piece of legislation entailed. I can't say whether it was wrong or right, because I didn't read it. But I know Palin has never stared down at a child that has spent the last year on a breathing machine with bedsores, infections, and eyes so consistently wide and dry they look more like prunes than eyes, if she had her pontifications would have been a little less polarized and "anti-death".

One thing I see time and time again is how poorly educated american politicians are about medicine, they are isolated from it. Whether it's the media clouding the picture or it's just laziness on the part of the politicians, they have no empathy or understanding for the less fortunate. It's sickening to watch a political debate on a major news channel about medicine, especially when no medical expert is involved, they throw statistics around that they have no comprehension of...some they actually had to have made up. My one piece of advise is that when medicine becomes a political debate again, as it always will, close your eyes and cover your ears. Go online and look up the stats, decide for yourself, understand the issues from objective sites, hell read wikipedia if you have to, but do not listen to what either side has to say about the issues in question, you'll be getting your opinion from someone little more educated on the matter than a picking a random man off the street.

Newbie Doc

Residency

Just FYI, if you have any love of your self image, medicine isn't the greatest for you. In one year of residency I've gained 20 pounds and people have gone from telling me I look Brad Pitt to telling me I look like Elton John...what a difference a year makes. Bubububu Benny and the Jettssss.

Elton John :/

Happier Notes

On a happier note, I was walking in to clinic the other day and I ran into the mom of my friend from "A Real Goodbye".  Despite all probability, he's actually doing really good.  His MRD is 0 already, (that stands for something like mean residual disease, which is the residual cancer left in the body after chemo).  Having responded early is a great sign, although he isn't out of the woods yet, it's looking a lot better than it did. I went by and saw him on my lunch break (he was receiving transfusions), he looks tired and the steroids have put on some weight in the last month, but all things considered he looks really good.  I guess that's a lesson for me to stay positive.  I always wondered how so many of the heme-onc docs can stay positive when they here prognosis like his and maybe it's because it's not up to the statisticians and docs who lives and dies, whether you believe it's a cosmic coin toss or a God up in the sky looking down, something else does.

Newbie-Doc

Happily Dreaming

Chelsey is a little 7 year old girl with a chromosome abnormality. No one has seen this type before, it's new and unknown, and as such hard to treat. She experiences periods of apnea (where she stops breathing) for no known reason. For these spells she requires a tracheostomy so that when she has these periods they can easily hook up the breathing machine for her. I'm vastly simplifying her condition, but given all her other complexities and her quality of life, which is poor, her parents have decided to sign a DNR or do not resuscitate order for Chelsey. While she hasn't had another apnic spell yet, the next spell will likely be her last.

I met her at a very special respite house, which my city has been blessed with. Many states are without anything like this for children and many of those that do are put to shame by this "house" which I found myself at. Imagine going to live in a small cottage filled with people and things that were there to make your last days, happy days, that's what this respite house is to the children. To the parents of these chronically ill children, this is a break, an oasis in the middle of a life spent up caring for their unfortunate loves. If a child qualifies, the child can stay there a total of 30 days, used any time during the childs life. If the child is placed on hospice with a DNR, they are allowed an unlimited stay.

I was to meet a nurse there for home visits today, but because she didn't have any, I got to participate in Chelsey's Wish. While at the house the children get to ask one wish that they would like granted, some ask for movie stars to visit, others ask for smaller simpler things, but this house and it's staff go out of it's way to make it happen. Chelsey's wish was to be a nurse when she grows up at this specific respite house.

Today when she awoke, she was given badges and scrubs to wear. She checked in at the clock and she had her first day ever as a nurse. I can't describe how amazingly happy she was as we traveled around to patient rooms interviewing patients with her notepad and listening to them through the stethoscope. When she'd had her fill, we took her to the family room which had been redone as a triage center. Gurneys and wheel chairs filled with large stuffed animals were found scattered through the room. In the corner a large camping tent had been made out as her nurse/doctors office and we'd set Carl the Gorrilla at a desk outside as her nursing manager. Inside the tent, a makeshift cot for a patient was made up. One side was stacked with nursing supplies from thermometers to IV kits. Something like this may sound so mundane to anyone else, but to her she stepped out of her illness for a day and was a kid in a kid's dream. One by one, I brought her the patients who were lined up outside to see her. We treated everything that morning from an abscessed tooth to splinting a Alligators broken tail. Although her condition leaves her chronically fatigued she "worked" tirelessly until all of our patients had been seen...I even asked her once if she needed a break, to which she replied, "More patients!" Every patient she sent away healthy, with a hug and a sticker...some with splints, some with bandages, all with imaginary smiles. We ended it all watching her favorite movie "The Lion King" surrounded by all the patients that she had helped, during the movie I heard her quietly state to herself, "This is the best day ever." I left her with a big smile and a bigger hug. I was told later that night, she quietly passed away. I'll never forget how happy she was, it was a great privilege to have been present for that. I like to think that she died just as she lived, happily dreaming.

I Save Lives?

Just a quick post on saving lives.  I always thought it would be a regular occurring thing where someone was rushed in and we brought out the paddles, after a few jolts the person would be back from the dead.  Things like that do happen with car crashes, really bad infections, ect. but the majority of "life saving" goes on without you realizing it, unless you stop to think about it. Such as the kid with really bad diarrhea whom you give fluids to by IV. It's second nature to do so and really not a big deal...but he would likely die without it.  Or the little baby who was born early and doesn't have the "stuff" in his/her lungs yet to breath...we just intubate for a quick second and pump in the stuff...no big deal...but kids would also probably die without that...or the last one, mentioned in my previous post, vaccinations.  It's a simple shot that, if you haven't seen the actual diseases, SEEMS like a slight inconvenience to the patient...but again those shots are saving lives.  I guess the point of my post was that sometimes I get caught up in the automatism of what we do and forget what a huge privilege it is to have an effect on so many.  I'm NOT saying I'm special, these kids would likely get saved without me and a good deal would survive without these treatments, just that when you think about it medicine has gotten really good at saving lives without most people realizing it, even the people who are doing the saving.

Newbie-Doc

Vaccinations

Vaccinations are kinda of a sore spot for pediatricians. The media often portrays it poorly and as a result we often find ourselves explaining that vaccines don't cause disease..."they prevent disease!" we explain in exasperation. FYI Don't listen to this if you are easily offended by the F word (i think it says it once.) But it's very informative, medically supported, and entertaining.

So I watched it again. It says it twice. Sorry not the most tasteful way to get the point across.

Continuity

So I haven't written about outpatient very much, for the simple fact that I wasn't doing much there. I saw three to four patients every tuesday afternoon last year, most of which I didn't feel comfortable "doctoring" on my own, so I would have my attending come in after I had seen them. Halfway through last year they "graduated" our class and gave us the option of seeing patients on our own if we felt comfortable with doing it. Since then my enjoyment of outpatient has grown in leaps and bounds. Since that time I've been slowly growing a base of "my" patients not just anybodies patients. Although I don't plan on staying here and growing a practice I am relieved to see that I am capable of sustaining myself and of holding my own against even friends of mine who I feel are superior doctors, it's a huge ego boost. Yesterday, I had a clinic schedule full of patients that were there to see me. I even had some walkin's (those that aren't scheduled) that were there to see me and when they were told that I was full and they couldn't see me, they re-scheduled! Two weeks ago I had a couple with a new baby request me after one visit, thought they have extensively delt with residents through two other children who had chronic conditions. I know this is in no way a comment on my medical skill, but non-the-less I take it as a huge compliment, that whether by my affect or by my treatments I am doing something right. It's at the same time scary that I have people expecting a certain standard from me and I honestly don't know what I'm doing different than anybody else. I guess as always I'll stumble and bumble and somewhere in there I will find my way.

Newbie-Doc

I Want a Danger Meter

Have you ever had an occasion where you've been really poisonous, almost to the point where you knew there was something wrong with you. There are times when I am "grumpy" and I know why I'm that way. But since becoming a doctor, there have been times when I come home and I am nasty to everybody around me.  Today, I was like that.  It wasn't till later when I was talking/apologizing to my wife that I finally struck upon the anger that was fueling all these toxic feelings.

There was a 1 month old I examined who over it's short life thus far had suffered several rib fractures, a skull fracture, currently had several bruises, and several breaks of his long bones. While questioning the mother about this I was perfectly polite. It wasn't until several hours of picking on my family and myself after work, that I wondered why I was so angry...and then when I thought of her again I exploded...I wanted to kill her...her indifference to her child's condition, the way she could smile in the face of it all...I don't know if my mind was trying to protect itself while I was with her by closing my mind off to the conclusions that I should have naturally come to, but as soon as I thought about her at home it was like my mind had a poisonous bubble of puss growing with increasing pressure and as soon as I thought about it I popped it and all that hatred and anger came rushing out.  She is either too stupid to know her child is being beaten or she is protecting those who have done it to her son or she herself is doing it and trying to get away with it.  In either one of those cases I hate her.  I know I'm supposed to remain objective and be the "doctor" that non-judgmental ideal...but I can't all the time, the worst part is I don't even know when I'm doing it, it just starts building up...I wish I had a danger meter on my forehead and somebody would just be like, "Hey Newbie-Doc, You better purge man, you're building up to dangerous levels."  I hate my job sometimes.

Newbie Doc

Bloopers

One of the pitfalls of a profession where everything is meticulously documented is that sometimes what you write isn't exactly shakespear...maybe isn't even exactly english.
Actual writings from hospital charts: FUNNY, BUT SCARIER THAN HECK

1. The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. She has no rigours or shaking chills, but her husband states she was very hot in bed last night.

5. Patient has chest pain if she lies on her left side for over a year.

6. On the second day the knee was better, and on the third day it disappeared.

7. The patient is tearful and crying constantly. She also appears to be depressed.

8. The patient has been depressed since she began seeing me in 1993.

9. Discharge status: Alive but without permission.

10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful

11. Patient had waffles for breakfast and anorexia for lunch.

12. She is numb from her toes down.

13. While in ER , she was examined, x-rated and sent home.

14. The skin was moist and dry.

15. Occasional, constant infrequent headaches.

16. Patient was alert and unresponsive.

17. Rectal examination revealed a normal size thyroid.

18. She stated that she had been constipated for most of her life, until she got a divorce.

19. I saw your patient today, who is still under our car for physical therapy.

20. Both breasts are equal and reactive to light and accommodation.

21. Examination of genitalia reveals that he is circus sized.

22. The lab test indicated abnormal lover function.

23. Skin: somewhat pale but present.

24. The pelvic exam will be done later on the floor.

25. Patient has two teenage children, but no other abnormalities.

A Clinic of Miracles

After my last post I feel obliged to post something happier, but the sad stuff is so much more frequent and potent. Being on the "cancer" rotation you would think everything is sad, but they do give you a glimpse at why these doctors do what they do, and you begin to see how it's viewed through their eyes.

Everybody hates inpatient-wards on this service, you see most of the attendings become grumps and worse ;) But every week we are given a half day of clinic and you might ask yourself what makes "cancer" clinic so special? Well could you imagine going to a place where cancer is curable? I try not to reference religion on here too much, but there are times in the Bible when Jesus healed people. It's hard to really understand the flood of relief, freedom, and gratitude that must have struck those people who had been miraculously cured, until you visit "cancer" clinic. This is a place where people's children have been GIVEN back to them and I've never seen such a happy work environment...honestly you need a better word than happy...like every person is appreciating every second of life they are given...it's a crazy level of happy. The doctors LOVE the patients, the patients LOVE the doctors, and it's like getting invited to be a part of a very tight knit loving family, they take you right in and you're allowed to take off your mask and beam with a ear to ear smile. That 5 hours a week is a patch of heaven in a month of pain, suffering, and hell.

Newbie Doc

A Real Goodbye

I'm on heme onc right now. I've seen a lot of patients since I've been on. I admitted one at the very beginning that's gonna stick with me. He's 20 years old, he reminds me a lot of my younger brother. During the short time I was his doctor we became good friends. He's a funny guy, he has a lot of good friends, doesn't take things very seriously...not even his leukemia...well not as serious as most, while I was admitting him we joked about all the stupid questions I had to ask him. In between questions we'd toss back and forth jokes and discuss movies and games. We talked about how he was enjoying the good college life, how he was having too much fun, how he was going to get his life together and two weeks into that plan, he's diagnosed with a death sentence. He's going to die from this.

Leukemia is a scary thing, just the word has broken men far stronger than me and I've watched in horror as it happened, covering my terror with my mask. That being said, it's something we've gotten more and more proficient at beating...did you know that a child diagnosed with acute lymphocytic leukemia (the most common type) has an 85% chance of cure in this age. I think that's wild, it's amazing that we can beat it that well...but my patient has too many risk factors, he's too old, he's got the wrong genetic markers, and the disease didn't behave "normally" when it first presented.

That being said, I know he's been briefed as to what his prognosis is, that he and I both know that his chances of survival are very small. I know that when I discharged him today, in all likelihood we were saying one of those "real goodbyes" it was in the back of my mind as I shook his hand and wished him luck.

I don't know what to take from this..."Party it up, life is short?"..."Cherish what you have?"...I don't know what to think...I don't have any wise things to take from this. A friend is dyeing and in a way to me, because of what I know (that there is little hope), he is already dead.

Newbie-Doc

On not being Robo-Doc

Suddenly I find myself in a scary position. I'm a senior resident. I'm expected to know something. I have doctors under my command. When I have a question I look around for my senior only to realize that it's my time, I'm the man whose supposed to have the answers...HA!!

Now I'm on cancer service, a service reserved for "upper level" residents. I don't have the slightest clue what's going on with my patients...they are "complex". I read constantly...I thought I "read" before.

Last night I had 3 leukemics come in. One parent cried on me. These days it's like I feel the sadness waying in on me but it meets a wall. I know deep down I'm really sad, but it's like a callus on your hand. The first time it stings, after the one hundredth time, you still feel the pain, but it's dulled. Sometimes when I'm tired I have to make a conscious effort to put myself in their shoes, so I can relate and they don't feel like I'm robot-doc. It sounds cold but the "dulling" effect happens without trying, you might think it's awful, you might think you'd never feel that way, but I'd say roughly twice a week I have a parent cry on me and I have to comfort them, you become very good at it and you become very relaxed in situations where the person sitting a crossed from you is flipping out. The point is that this would happen to anybody, it's just one of those things you don't expect. The thing you never imagine is that the hard part is pretending to act like you haven't been in that situation a billion times and acting like each new crisis is actually a new crisis.

Why do you do this? There's the obvious reason, you don't want the parents getting hostile. There's the reason that you first imagine, the slimey doctor is trying to buddy up to the person in trouble. The reason I do it is because the family and you have to be on the same side. A patient won't get better if they don't take the treatment and they don't believe in you, so some of what I do is selling them on me. It sounds disingenuous, but it's for their own good. I believe at the end of the day a patient wants a human treating them, not a robot, not even necessarily a doctor.

Newbie Doc

"Not-Hell"

When you think of heaven, what do you picture in your head?  I'm not asking you a religious question.  I'm asking you a question about what your "ideal" is.  When I imagine that perfect moment, I see all my family and friends hanging out together, I've got a relaxed buzz like after knocking back a bottle of beer, and everybody is in that mood where a smile or laugh comes as naturally as breathing.  There's a light,cool breeze blowing through your hair and as you kick back in your chair or toss a bean bag into the air, you realize simultaneously how much fun you are having and that the party isn't even close to over.  That feeling right there is perfection to me.  The funny thing is that we all have these ideals in our heads and we all, whether we consciously know it or not, are trying to get to that place whatever that place is for each of us.  When I was younger, when I was making the choice to become a doctor, there was a part of me that made that choice because I thought it would be a sure route to that "sweet spot".  While there were more reasons than just one, one of my reasons was the following:

If I'm a doctor, then I will make money, I will retire early, and I'll get to spend lots of time with my family and friends.

Currently I am coming to one of two conclusions.  I was WAY wrong...or the more probable you have to go through hell to get to heaven.

I've been relieved of the fantasy that I will make a lot of money or that I will retire early, but as I've matured I've learned that I can totally live with that.  What I'd like when I'm done with all this is a job that I, at least, like and enough free time that I can occasionally take a couple of free breaths around my family and friends.  Even if it's not quite my "heaven", I'm willing at this point to settle for "not-hell". ; P

Newbie Doc

The Rack

It's been a rough couple of months for us.  Seems like we go from work to Bode to back to work with some sleep speckled  in between.  My wife gets up at 4 in the morning, goes to work, and depending on the day gets home around 6 to 8 at night.  It doesn't matter how easy the rotation is Bode makes it a tough internship, although I wouldn't change a thing it's a rough time when we get a day off in fourteen.  I suppose if another doctor, an older doctor were to read this he would laugh and tell me how it he or she had it a lot tougher, maybe they did, but as a friend of mine put it, "internship is tough for many different reasons and hours is only one of them". 
The powers that be are slowly dialing down the number of hours the interns can work around the country.  They think this will somehow save litigation, save lives...maybe...I think the people pulling the strings would be surprised at the majority response from those they are "saving" from all these extra hours.  The truth is that there will never be another time in our lives where we have such a safety net of senior residents and attendings to catch us before we fall, to catch our patients before we drop them.  If there is ever a time for a doctor to make mistakes and learn that time is now.  We have 3 measly years that prepare us to fly on our own, to learn knowledge that has taken centuries to accumulate.  Those of us who feel that weight on our shoulders look at these changes the way our attendings do...as handicaps stunting our growth.  As a medical student hearing talk of these hour changes I often laughed as the doctors whined about how it would hurt us.  To myself I thought, "Pshhh, hurt YOU is more like it, when we HAVE to go home, who is going to do all the scut work you normally count on us doing".  Only now I realize the scary truth to that question I asked myself, the answer is no one will do it.  As a student I looked at the medical world without responsibility, I looked at my family and friends as my only loyalty and responsibility.  For me residency isn't just rough because of "hours" or the "sad stuff", it's tough because in realizing that I will one day be "on my own" I suddenly discovered a responsibility to my patients both present and future, a responsibility that pulls me by the arm in one direction while love of my family and friends pulls me in another.  Sometimes you feel like you can't make gains at one without loosing ground on the other, my greatest fear is that I would let one slip through my hands which are knuckled-white at the moment.

Newbie Doc

I & D

One of the generally most recognized things in medicine is that an I and D procedure is one of the most rewarding experiences in it.  I and D stands for incision and drainage...of an abscess...I know...this sounds pretty disgusting...it is, but there is something so symbolic about removing the infection...draining it away.  It's like the puss and nastiness stand in one to one with the patient's pain and as you lance and remove the white curds and slime the patient's pain subsides and they are instantly better...like magic...few healing events in medicine come so quickly and with such little cost to all involved...all the patient must do is open up...literally.

The human immune system is quite an amazing thing.  It has an incredible built in memory, a cascading response system, and very few weaknesses...that being said it does have them and occasionally it runs into something which it can't fight off, kill, or digest.  When it does run into something such as this, it does a very logical thing, it creates a quarantine called an abscess.  The area around the infection or damage becomes so inflamed and swollen that the swelling (edema) closes off the blood vessels entering the area...effectively all routes in and out are cut off, leaving the invader to grow, multiply, and war with the white blood cells; but only in the area which the body has surrendered.  This counter measure of the body isn't a solution, it's a last ditch effort to keep the intruder from taking over the body and with it comes some untoward consequences.  The top three problems in forming one of these quarantine areas in the body is that, one, the bacteria isn't dead and there is still a high risk of "seeding" the rest of the body, two, if nothing comes out and the bacteria continues to grow a significant amount of pain can be caused by the ever expanding ball of puss inside your body, and three, the abscess protects the invader from blood born treatments such as antibiotics because if nothing can get out through the blood vessels, then nothing good can get in.  So in medicine and in life there comes a certain point where the pain is too great and the treatment hindered too much by the walls you put up around your embarrassments, your fears, and your failures and it's then that the site has to be opened and drained away or your risk loosing yourself, maybe your soul to it, of thinking only of that pain, and forgetting yourself and the love you have for those around you.

I hope that you never have to sit in front of loving parents and tell them that you don't know whats wrong with their son, that something is attacking his brain, and you don't know what it is.  All the tests I can offer, all the treatments that may become a possibility once we know what it is, none of that counts for anything against a child that looks like a walking skeleton, their child.  I walked out of the hospital this morning thinking I handled it very well....I did...but as the day went on I felt it eating on me, I felt the abscess growing and here I am typing this hoping this will afford me some comfort, maybe drain me of some of the poison in my veins...though I'm not sure I deserve it.

Newbie Doc

Catching A Break

So I was in the ED the other night and a little 6 year old boy came in who had been playing at the park on a bench about 4 feet up. Unlike most of the children who come in here with a cough and a fever or a splitting headache...maybe even a split head...this one had fallen just so on a cement curb and halfway up his right forearm had snapped it backwards at 45 degrees. Now I had heard that should something such as this occur we were, as interns, expected to do the brunt of the treatment which means managing the sedation, reducing the fracture, and casting the poor soul...this is all under the supervision of someone who is skilled in all of this (my attending). Now I've sedated probably 10 or 12 children and I've placed casts and splints on a whole lot more, but I have never manually reduced a fracture. The majority of fractures that you see are hairline and only need support or they are fractured in such a way that you don't dare mess with them (ie. Cranial fractures or growth plates)...but this kid had landed on his arm just right and thanks to his thoughtfulness...or thoughtlessness that night I got to see and feel exactly what resetting a broken arm feels like. With trepidation I fixed my mask tight on my face, no smiles, no frowns, no wide eyes of terror would peak out from behind the frozen visage that had become my face. I wrapped my hands around his forearm just below the break and placed my thumbs over the two bones in the forearm above the break. As I had been instructed I
thrust my thumbs foreward pushing the broke arm suddenly into perfect alignment. Possibly it was the addrenaline giving me extra reserve...but maybe it was that easy...the was a crunch and snap like twisting a piece of cellary to breaking or snapping a dry twig and suddenly the arm was back in alignment and the repeat radiograph looked like perfection. It was done and so was I, in the mere seconds that seemed to elapse while treating the boy it seemed that an actual hour and a half had passed...as I walked out of the hospital to my car in the dark I allowed myself a great big smile...it had been a great night.

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