Israeli Departed

The new airport that recently opened here in Israel is spectacular. It's very reflective of the natural resources of its homeland. The rocks have a natural beauty and it's full of historical and religious articles displayed in shelving embedded within the rocks.

It's called 'Ben-Gurion-2000' and was scheduled to open at the end of the last century. After a slight delay of 6 years it finally opened and was worth the wait. It's huge and easily replaced the old airport, called 'Ben-Gurion'. As I walked through it I wondered what secrets it housed in terms of high-tech security. I arrived at this airport earlier this month to spend some time in Israel before starting my last year of residency.

I love this country. I've always loved this country. I was born here and I hope to die here one day. This country has everything anyone needs. It's got history, pride, tradition, variety, multinationality, scenery, soul, beaches, great food, great wine, and of course, beautiful women. The women are so beautiful that sometimes I wonder if it's really a holy war they're fighting here or just something more along the lines of Machismo.

It's so unfortunate that the people of the world only know Israel and the Middle East for the violence that occurs here. Rather, it's so unfortunate the violence occurs here at all. This place is so much bigger than that, yet, that's the first thought that comes to anyone's mind. Terror is the topic of the day. It rules the news; it rules the politics and life. Tragic and beyond comprehension to anyone who has never had the misfortune of witnessing a bombing, a mass murder of innocent lives. I've had that misfortune, I'd rather not discuss it now, it's really more along the lines of a horrible dream I've lived through.

It's so fascinating to me how in the middle of this chaos, this murder and this beauty, beats the hearts of a people that simply love. They love their country and they love each other. And, they have a character, a mentality that's simply hard to describe. This is a sort for impatient love. But it's so much more. It's ruthless and merciful at the same time.

My friend once described the difference between Israel and New York (where he lived at the time), he said "In New York they will pound you and pound you until you collapse to the ground and then they'll leave you there. In Israel they'll do the exact same but when you collapse they'll pick you up again". I guess it's the closest I can come to describing it. I'm sure some of you may disagree with me.

The mentality of Israelis is the secret and when I moved here to study medicine it took me a whole year to understand it. The best advice I received came from a Russian woman who cut me off at the local McDonalds in Haifa. She told me "The line in Israel is horizontal, not vertical". I came to learn the truth of that statement rather quickly. Most people would call that rude, I just call it "Israeli", and it always makes me smile.

Yesterday, I walked into a mall in upper Tel-Aviv. Of course, I had to endure the standard security measures as a security guard gave me a physical exam before I was allowed to enter. He jokingly patted my belly, since it protruded from my shirt and told me it looked "rather suspicious" (devilish smile). I told him I'll try to lay off the beers. We laughed, I miss that.

Last week we were on the beach, in a café. We ordered a Corona, and a 'strong' espresso. The waiter jokingly asked if there was any other way to make an espresso? It became a common theme and we began to order a 'strong' coke, a 'strong' salad. He returned quickly and gave us the Espresso, along with our 'strong watermelon', as he put it. I miss that too.

The past week was spent visiting old friends and family. Physicians I studied with who opted to stay here rather than return to the states. Friends I've had since I was a tiny toddler running around the streets naked in the sun. Aunts and uncles and grandparents who really want to see Jordan but pretended to miss me so I'd bring her along for the ride. It's been great but a rather exhausting week. I've been updated on the politics, the television, the books and the medicine.

The hottest topic of debate here are the settlements. Sharon would like them evacuated, as would the Palestinians and the U.S. Many see them as a barrier to peace while others see them as simply another excuse by the PA for delaying peace. The country is seriously divided over the issue. The clearing of Jews from their homes is heart-wrenching, even for those in favor of detachment. Soldiers are pictured daily in the newspapers as many tear off their helmets in defiance. They refuse to remove fellow Jews from their home. How can we judge them?

Along the streets people have taken to tying orange ribbons on their car if they are against detachment and blue ribbons if they favor it. Jerusalem is as Orange as a citrus Florida field, while Tel-Aviv is blue as the sky. The highways are a kaleidoscope of color. Debate, is the one constant here. It thrives in the hot air. But I promised to refrain from politics, simply because there's too much of it and I would not be able to do it justice.

For a country the size of New York this area generates news at a frightening rate. Israelis listen to the news incessantly. There's an update every hour and it's even played over the speaker system on the public busses. There's simply no escaping it. Not that you would want to, it's part of what makes this place so amazing. It's terrifyingly wonderful. Everyone is a politician and they all have three views on every topic.

This week I'm laying off the local events and concentrating on my tan, the beach, the pool and the alcohol. Let's not forget the watermelons. All I really ever wanted was just to relax and take a break before returning. You know a little sand, some beach, a beer and some coochi-coochi. Can it get any better than that? Oh well, at least I got some sand, a beach and a beer. Oh yeah, and some watermelon.

I Just Can't Stand It

I'd like to think it's not because the hit counter daily average keeps edging slightly lower that I force myself to write an entry, so I'll continue to delude myself.

Since any such 'vacation' entry must be short and sweet (no sense wasting perfectly good sunshine) I decided to post some rules that I love-to-live by. Some of you may recognize these:


1. GOMERS DON'T DIE.
2. GOMERS GO TO GROUND.
3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
4. THE PATIENT IS THE ONE WITH THE DISEASE.
5. PLACEMENT COMES FIRST.
6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14 NEEDLE AND A GOOD STRONG ARM.
7. AGE + BUN = LASIX DOSE.
8. THEY CAN ALWAYS HURT YOU MORE.
9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
10. IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER.
11. SHOW ME A BMS WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
12. IF THE RADIOLOGY RESIDENT AND THE BMS BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
13. THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

Middle East Mission (Part 3)

As I attempted to contact my handler one of the group's leaders (shown here) intercepted me. He attempted to drown me but after a long and valiant struggle I was able to fight off this "Resident". The information now rests with the United States government. What they choose to do with it is none of my buisness but I would not be surprised if this ends up in Guantanamo.

All US citizens should sleep well tonight knowing such capable espionage is being conducted and by none-other than the Future Intern.

No sign of Usama yet but I will not leave this Middle-East until all enemies of the American people are dealt with properly.

Middle East Mission (Part 2)

I disguised myself with this bulletproof foam and penetrated an underground group called the "Residents". After obtaining their confidence, they entrusted me with the ultimate truth, one which I am confident the American public should know. The true Weapons of Mass Destruction are a group better known around the world as the "Third Year Residents". It is precisely these "martyrs" who have nothing to lose. Their commitment to long work shifts resulted in mind numbing sexual deprivation and they have become easy pray for promises of 72 virgins in later life. They must be stopped.

Middle East Mission (Part 1)

Dear readers;

I was recently approached by the CIA to go deep undercover in a region currently in turmoil. I cannot specify the full details of my mission but I was sent to unravel the mystery of the missing WMDs and in the process I uncovered some critical information.

It’s Been the Best of Year and the Worst of Year

My second year of residency has come and gone. It’s the one good thing about a blog in that it allows you to reflect on some of these experiences. Even better, it allows me to examine my progression and who I have become. Officially, as of eight this morning I am on vacation for the last two weeks of the second year, in essence, already a third year resident.

You’ve been there for it all. From my beginnings in the ICU and CCU and as I moved on to night float. When I had my own team and when I quietly served my electives. You've remember the Widow Maker and my trepidation. Times I was sure and others when I wished for divine intervention. Times I was ecstatic and others when I wished reality would leave, felt close to anoxia. You've shared my emotions and along the way cheered me on, some useful bit of advice, a kick in the pants. You pulled me from the mud, wiped me off and said “Go get’em Madman”.

It was a long and wonderful time, when I’ve witnessed my growth and changed in ways I never imagined. My thoughts meant all too much for me as I translated them to words. They became the experience. This forced me to take it all in. At times I wish I hadn’t. Paradoxically blissfully aware these are experiences others only dream of. Moments that change lives.

I’ve witnessed death in its most despicable form as it slowly drains all strength from those others depend on for life and inspiration. I’ve felt disease in its final stage as I pounded and electrocuted a father’s chest, trying to breathe life in. I’ve watched the monitor as a heart I cared for beat slower and then slower still until the pleasant rhythm ceased. I have lost many patients and with them many friends.

When I look back on the second year though, I would like to remember others who have neared death’s valley, who with our help, returned home to their loved ones. TYTD comes to mind. I helped them do that. Late on my twenty second hour I helped them do that. They will never know. Most probably, they will never acknowledge their near non-existence or my sacrifice, but when I look back at those days I will remember them and hope that they are making good use of their time. It is time paid for in the tears, sweat and energy of others who have come before and those who serve now.

Most of all I will remember this year for the biggest moment of my life and the beginning of hers. The birth of my favorite intern was my defining moment of Post Graduate year number two and I will forever remember it as 36 hours that transformed who I am. Today, I officially begin my vacation.

How I miss the Mediterranean Sea, its blue waters as exquisite and pleasant as the sand that lines its beaches. It’s been two years since I admired it from within.

Tomorrow evening I am flying to Israel for two weeks to join Future Intern and the wife who got a head start. I can’t think of a better way to spend my time then sitting on a beach chair with a beer on the side table, a watermelon on my plate and a little girl in my arms.

I may try to blog a bit while there. Maybe show some pictures of the nothing that I’m doing. I will refuse to talk politics or watch the news and there will be no medical blogging at all, sorry.

When I return, I will be a third year resident with all new interns. There will be new Chiefs and new Attendings and I will have to begin searching for a real job. That sounds amazing, a real job!

For now I hear faint whispers making their way through Europe and over the Atlantic. Aha, I recognize it now. The waves of Haifa beach are calling my name.

Le’Hitraot

Friday 10 Random Things I Asked My Interns to Do Today

1. Turn a bedbound patient with no mental status over so we can have a look at his decubitus.

2. Clean off that same decub and put dressing on it.

3. Go hassle the CT tech to do a STAT CT on a patient we suspect had a leg clot travel to her lungs. I told him to take some chocolate.

4. Draw an Arterial Blood Gas from that same patient.

5. Smack the third year student for slacking off (Lightly of course!). It was a joke; Intern did it anyways. I’m so proud of her.

6. Call Infectious Disease for a consult. This is because I hate talking to the fellow on call that day. He’s such an ass!

7. Pull out a Naso-Gastric tube. This was one of the few happy things we get to do.

8. Put a peripheral IV line in a patient.

9. Get a urinary toxicology panel.

10. Sit down and enjoy the Dunkin Donuts and coffee I bought them for being awesome interns. We finish our rotation together this Sunday.

An amusing moment during rounds this morning when a patient known to shoot up with cocaine and heroin requested a central line so that we won’t stick him so often. That was funny!

The Skeptics Circle

The first time I found Skeptico it was through a google search I conducted on a movie called What the Bleep do We Know. I was getting hassled by my family to watch it because they, again, felt it was scientific proof that god existed.

Skeptico wrote a good review of the movie. Needless to say, once they were made aware of these paradoxes the nagging disappeared, for now.

This week's Skeptic's Circle is hosted by skeptico (How appropriate).

Nasty Week

As you might have noticed I've posted less than usual this last week, or at least nothing I consider substantive. This is because I'm in the midst of a dayfloat rotation. Which is kind of like a night float rotation except during the day (I hate to state the obvious). Tonight the wife and future intern left to Israel for a three week vacation. I'll be joining them next week when I get a much deserved break from the world of chaos I currently occupy. After that it's on to the third year of my residency. It will be my final year of residency but I will post a lot more about this soon enough. I just realized that it may end in me having to change the name of the blog, or possibly, find another Mad House.

While I'm away toiling with write-ups I thought I'd attempt to keep you entertained. This has nothing to do with the theme of this blog except that it's author found it very funny, so he decided to post it here:

"Dear Technical Support:Last year I upgraded from Girlfriend 7.0 to Wife 1.0. I soon noticed that the new program began unexpected child processing that took up a lot of space and valuable resources. In addition, Wife 1.0 installed itself into all other programs and now monitors all other system activity.Applications such as Poker Night 10.3, Football 5.0, Hunting and Fishing 7.5, and Racing 3.6. I can't seem to keep Wife 1.0 in the background while attempting to run my favorite applications. I'm thinking about going back to Girlfriend 7.0, but the uninstall doesn't work on Wife 1.0.

Please help, thanks

A Troubled User"

"REPLY:

Dear Troubled User:

Many men upgrade from Girlfriend 7.0 to Wife 1.0, thinking that it is just a Utilities and Entertainment program. Wife 1.0 is an OPERATING SYSTEM and is designed by its Creator to run EVERYTHING!!! It is also impossible to delete Wife 1.0 and to return to Girlfriend 7.0. It is impossible to uninstall, or purge the program files from the system once installed.

You cannot go back to Girlfriend 7.0 because Wife 1.0 is designed to not allow this. Look in your Wife 1.0 manual under Warnings-Alimony-Child Support. I recommend that you keep Wife 1.0 and work on improving the situation. I suggest installing the background application "Yes dear" to alleviate software augmentation. The best course of action is to enter the command C:\APOLOGIZE because ultimately you will have to give the APOLOGIZE command before the system will return to normal anyway. Wife 1.0 is a great program, but it tends to be very high maintenance. Wife 1.0 comes with several support programs, such as Clean and Sweep 3.0, Cook It 1.5 and Do Bills 4.2. However, be very careful how you use these programs.Improper use will cause the system to launch the program Nag Nag 9.5.Once this happens, the only way to improve the performance of Wife 1.0 is to purchase additional software. I recommend Flowers 2.1 and Diamonds 5.0.

WARNING!!! DO NOT, under any circumstances, install Secretary with Short Skirt 3.3. This application is not supported by Wife 1.0 and will cause irreversible damage to the operating system.

Good luck User."

Grand Rounds and the L.A. Times

Never ignore your emails. At least that's what I learned today after catching the recent article published in the L.A. Times on Physician blogs. It features a few of my favorite blogs in The examining room and The prolific Oncology Writer. I do recall being sent an email to respond to but I ignored it. Figures it was just another Spam mail. Oh Well.

Having read the article I've come to realize something that I often forget. What we do is a mystery to people who don't understand medicine. This is easy to forget on your twenty third hour. In retrospect, I often do realize that what I do is "F*cking Awesome"! It's a mind rush I usually only get in retrospect, since I'm usually so anxious while it's actually happening!

So to get a better feeling for it go check out Grand Rounds. It's hosted by Medgadget this week.

Also, I wanted to direct your attention towards a new blog that's captured my attention. Imagine rounding every morning with the world? Enough consults for you?

Skeptical Agnostic

In the last few years I’ve become the black sheep of my family. Mainly because, in contrast to my very religious parents and brothers, I am not a big believer and quickly trending towards non-belief. This often gets me into some heated arguments but I’ve learned that I won’t shake the faith of others and have become content to be left alone. Hoping every Friday that this subject doesn’t come up.

Recently, in another attempt to steer me towards salvation I was handed a book to read. The name of the book is “Permission to Believe” by Lawrence Kelemen. The author attempts to use a rational scientific argument to prove the existence of god. Too bad he uses the standard creationist arguments and incorporates truths in science with half-truths, sometimes even outright lies. A non-scientist would be non-the-wiser and would easily accept his version of scientific “evidence”.

I did, however, find his first argument interesting and I thought that the Skeptics Circle would be a good place to share it:

There are three attitudes one can have towards god. First, one can be sure god exists; such people are called ‘believers’. Second, one can be unsure of the existence of god, such people are called ‘Agnostics’. Finally, those who believe god does not exist are called ‘Atheists’. The author contends that only the first two positions make sense and that the third does not.

Can one be rational and believe in god? Certain events may have indirectly convinced him/her of god’s existence or that person has direct evidence of god. This is therefore a reasonable and an acceptable position.

Is it rational that one would be uncertain of god’s existence? Until one has direct or indirect evidence of the existence of god it is reasonable to remain unsure.

The author then contends that it is unreasonable to be an ‘Atheist’. Follow me:

He contends that there are three types of ‘Atheists’.1. A small group of ‘Atheists’ grew up in a home devoid of religion. Religion was a non-issue for them and therefore remains a non-issue.

2. Another smaller group of ‘Atheists’ were raised in a religious home and became atheists as a form of rebellion. They do not believe in god for emotional, rather than, intellectual reasons.

3. The largest group of atheists are those who examined the idea of god and could find no rational evidence for the existence of such a power. Most Atheists fall into this category.

Here’s the catch, since this third class of Atheist has never found any evidence to the absolute evidence that there is NO GOD (Since that is impossible) they must admit their position to be irrational and therefore must retreat to EXTREMELY SKEPTICAL AGNOSTICISM.

I thought the argument was interesting and so I thought I’d throw it out there for my second Skeptics Circle. I’m sure I’m setting myself up for an Orac rant, or another one of the writers I love to read, but I would enjoy reading their counter-arguments.

Number Seven

This is the Future Intern and I decided to take time from my busy schedule to deliver my gratitude to the few bloggers out there who had comments about the previous post, specifically advice number seven. Yes, you know who you are. In fact, I so wanted to thank those few that I hacked into the Madman’s blog.

Seems my Resident upset everyone with good’ol #7. He thought he was doing everyone a favor he says “Just a few tips on how to coast through residency”. He didn’t even consider that number seven would inflame readers. He thought number eight was the gem of the post. What a dummy!

But I’m here only to explain that he probably was intending to say that if a patient has multiple complaints THAT DON”T MAKE SENSE, it is very likely that there is a psychiatric component and that maybe you should attempt to explore it. Not that one should completely dismiss it!

But you had to have your say. He comes in storming into the call room this morning talking about how this and that study proved this and that and that he was absolutely right.

So here’s where I express my sincere gratitude to those few altruistic readers who decided to point out the obvious. HE decided that I should write a post about it with proof that what he said wasn’t complete bullcr*p. Me! The Intern who just came off a twenty four hour call. Me!

Thanks everyone. I was only 72 hours away from a beautiful vacation after a year with a Resident otherwise easily confused for a lunatic and you get me assigned to a paper?

Sincere Gratitude, (%^$##*)
Future Intern

Friday Song List

It seems every blogger these days is posting the friday shuffle list. Unfortunately, I don't have enough time to sit next to my CD player on fridays. So you'll never find this list here.

But, raise your sad little head young ones, I've thought of a more medical tradition. Every Friday I can list the first ten things I asked my intern to do that day. This way, you'll get to understand what it's like to be an intern and I get to reflect on how much it really sucked! Not to mention, it will certainly encourage me to get creative with my interns on Fridays.

I do remember one thing from my internship year: When your resident gets "creative" that's not a good thing.

Recommendations

As the medical school year comes to an end hundreds of graduates prepare for the grueling year they’ve been anticipating their whole life. Graduations are celebrated across the country and the seniors, thinking about their fleeting time, come to realize that the now they must apply all they’ve learned in their new world, the medicine floor. I thought I would take the time to give the incoming class of interns a few suggestions I think will certainly come in handy.

The most important thing to remember is that like any other workplace the hospital is it’s own society, with it’s own rules. Each is different in that it has it’s strentgths and its faults. You still do not know most of these about your particular future place of work, no matter how many times you interviewd there. More importantly in the hospital, like the real world, it’s not what you know but who you know. If you want to be an effective intern, know everyone.

Let us begin, remember, the keys are in the details:

1. Most of medicine is common sense. You’ve heard this so many times and yet you don’t understand it yet. You will, later this year.

2. Don’t make your resident look bad. You will pay for that.

3. When you don’t know, find someone who will. This is really not about you. Anyways, we think you don’t know anything, regardless of what you really know. So take advantage of that.

4. You’ll hate the nursing, no matter how good it is. Understand, you will catch a lot more bees with honey. BTW, nurses can make your life hell so your choice will be smart and well-rested versus right and exhausted.

5. Having your own patients is so much better than seeing four new patients each session. This way, you will learn nothing. If you have a continuation clinic, know the months that you will be there. Schedule your patients to come back on those months. If your patient must be seen during a time when your not there, make a deal with another resident and send him your patient, so that he will send your patient back to you.Your patients will love you so much more for it.

6. Most of the time your diagnosis will be a symptom, that means, what you actually learned in medical school only applies less than thirty percent of the time. I’m not kidding!

7. If a patient has more than three complaints in one office visit the diagnosis is depression. There is no other diagnosis, don’t waste your time and our money.

8. You will need to bribe everyone. Since you can’t use money (You won’t have any) chocolate is the next best thing. You can move mountains with chocolate. (this is my personal favorite advice, consider yourself lucky to know this before you start, you can get any tech motivated with enough chocolate)

9. When you call a consult say “Hi, this is Joe Schmoe, intern in medicine” don’t say “Hi this is Dr. Shmoe” it just sounds more confrontational and is the key to a bad phone call.

10. Some operational alerts:
a. When a patient says he only drinks alcohol socially, your follow up question should be “How social are you?” You’ll be surprised.
b. When you ask if a patient smokes and he says yes your follow up question is not “How much?” but rather “What?”

Good luck guys. Remember, for any difficult question you always have two residents, yours and the MHM.