Future Intern Wishes You a Happy New Year

From inside my investigational lab where I can assure you we are making progress in the ultimate battle against some of the worlds’ greatest health threats, I wish you a Happy and Healthy 2006.

First order of business, this new anti-madhousemadman antibody. That should save a few thousand from that internal medicine doctor.

Carnivals

Grand Rounds is here.

COTV here

Bonfire of Vanities here.

Merry Christmas and Happy Chanukah

As 2005 winds down I am once again amazed at how fast goes the passage of time.

There is a sign posted on the stall room door in the Mad House. It reads “They can always hurt you more but they can’t stop time”. It’s a grim reminder of how demanding and grueling this job can be both physically and emotionally, it’s also derogatory. Such as the resident who complains of the patient who “dropped his pressure on me”, as if it was something he was consciously in control of. It’s like this blog, mis-directed anger written in a comical and sarcastic fashion.

One year and four months later I am still writing. This blog has allowed me to vent my anger and my frustrations. It has been a medium through which I have been able to connect with some of my readers and establish new friends. And it has allowed me to write, something I enjoy. Also, I was able to share with you my experience of an internal medicine doctor. It is something I will be able to reflect upon later on.

The holidays are upon us. Christmas is here. I am late with my warm wishes but that has never stopped me before.

It’s been an opportunity to read up on what I’ve written over the last year. I thought of including a top ten list. Reading some of the entries I was amused at my sense of humor. It’s not too bad, wouldn’t you say? I can write too. No wonder you read this blog.

Reflecting upon my blog is sort of funny. I was able to review some of my insane attempts at gathering readership. These included, but are not limited to, my blog parodies and my Gray’s anatomy reviews. They were entertaining but exhausting and I will never commit to staying up until 11 pm on a regular basis, during a medical residency, again.

But there was more. Remember the traveling story, or the introduction of the Madman that stands above, or the one before him.

I realized that during summer I shouldn’t write. For one, I don’t feel like it (During August I had two entries, both two lines long) and also I don’t write well when I want to get out.

But for now I will continue writing. Because I love to.

Mad House Top 10 of 2005: (as chosen by the Mad House Madman)

Recommendations for Personal Statements
A guide to AMA. And follow up.
Room 422
Problem Solved
CD4
Gotcha
Spectrum
PTT
A Small Percentage
Dangerous, Do Not Touch

And of course not a post, but, by far this is my most favorite entry this year.

Most of the wonderful comments you guys made have been erased by my attempts with Blogger/Haloscan/blogger. I'm sorry for that.

Merry Christmas to everyone and a Happy and Healthy New Year.

COTV

chekc out the COTV at Ravenwood's Universe

Grand Rounds

I've officially requested to host Grand Rounds again but until Nick approves my request you'll just have to go enjoy them somewhere else. Today, Medpundit, one of our first medical bloggers has the honors.

Unpeople Person

I find it troubling that almost all the fourth year graduating students in our affiliated medical school have no intention of entering primary care, or for that matter, internal medicine. What’s more alarming is the reason that they most often cite: “I found out I really hate to deal with patients/people”.

“So it’s not the money?” I ask.

Of course, it’s also the money, or lack thereof. Is it me or does the general trend go something like Jerry McGwire:

“Show me the money!”

I’ve heard so many lame excuses as to the sudden un-popularity of primary care among US graduates. Everything from blaming the medical schools for not promoting the specialty enough to citing residents for not making it exciting. Let’s cut the crap, bring some of the money back and watch how fast these graduates become people friendly again.

Haloscan Out

I am contemplating getting rid of haloscan and going back to good old blogger comments. I just have to figure out how to un-install.

Of course this means that a lot of comments will disappear, never to be seen again. Sorry guys, I can't stand this haloscan thing any more.

Too Many Ways to Die

Over the last three years I’ve developed a not so healthy case of generalized anxiety. It’s official; there are too many ways to die. Six million may be just a small exaggeration, but the point being: I know way too many of them now.

It seems I can invoke three climactic death scenes for anyone I know. You name a medical condition and I can think of ten horrible terminal scenarios that will part one with dear life. Diabetes, for example, causes complications ranging from a simple hyperglycemic coma to Diabetic Ketoacidosis, both potentially deadly. Even as I write the prescription for diabetic medications my mind trembles with fear at the thoughts of further potential complications.

“We tried to save him Dear Internal Medicine Doctor, but when we got there he had blood glucose of 10. By the time we finally got access it was negative 50.”

While most drivers worry about a high speed crash switching lanes on an interstate highway at 60 MPH, I worry about the driver in front suddenly having a tonic-clonic seizure. In a word, I find this new diversion “unhealthy”.

No one can accuse me of lacking imagination, or hypocrisy; after all, I’ve all but terminated myself a hundred thousand times over. I figure if things go well I’ll die of septic shock while my wife tries to urgently call paramedics. God will support my cause and due to unexplained reasons the four tires on the ambulance will go flat. I plan on having my jaw wired to prevent myself from being intubated, just for giggles. Maybe I’ll tattoo “DNR” on my forehead.

Of course, I’m anxious things won’t go as planned and I’ll get in the line of a perfectly good bullet, meant for someone else, on my way to an anti-gun rally. Each scenario just keeps getting more and more sarcastic and ironic, not to mention painful.

The next young man who complains of being abducted by aliens on his way to Pluto will surely get a STAT ride to psychiatry on my ER shift. It’s just that next time I may do one of two other things. First, I may congratulate him on a death scenario that even I could not have fathomed for such a healthy young soul. But in addition to doing this I may just ask him to “scoot on over” and make a little room for me on the stretcher. I think I need to come along for the ride.

Chalk another one up for the ER- Wait, I have to vomit first

Its moments like these that made me want to become a doctor in the first place. The strange thing about all this is how these rare moments happen whenever I’m doing my ER rotations. Strange, because I find I am able to spend very little time with patients, much less than I would as an internist, and yet there are these little sparkles of light. Maybe this is what draws emergency physicians to their specialty. Although, I’m betting it’s the fact that they get to intubate.

I’ll set the stage. It’s five in the afternoon and I’m preparing to draw blood on one of my patients when the receptionist pages overhead “Medical notification is HERE!”. Normally, a notification is announced minutes in advance thus notifying the physicians of the severity of a particular case that is on its way to the Emergency department. This notification was slightly late.

Suddenly, I see a young girl; about 26 years old, being wheeled towards the back while Emergency technicians are trying to give her oxygen with a bag. She is not moving any air. I can’t hear any breath sounds. No time to react. We establish a line and she is intubated almost immediately.

After the intubation a careful exam still reveals clear breath sounds, no wheezing, normal peak pressures on the ventilator. While before the intubation this was likely a case of horrible asthma, it doesn’t seem to be the case now.

A further probe into her past reveals this patient suffering of a condition called paradoxical vocal cord movement. A cause was not yet found but is probably psychiatric in nature.

She is extubated one hour later.

Now she begins to wheeze heavily and we re-assess our initial impression.

She spends the next four hours wheezing heavily, looking like she needs to be re-intubated. But, all the blood gases and the monitor shows she is oxygenating perfectly. I think I may be going on too much about this case but here’s why I decided to write about it.

Before my shift was about to end I went to check on her. Having looked to me like she was tiring I decided to attempt another blood gas. While I was obtaining the test I started asking her about her life.

“I have four kids” she said.
“Four kids?” I answered, surprised. “If I had four kids I would be here getting intubated every night”. She laughed.
“Where’s your husband?”
“At home with the kids”
“How are things at home?”
“They’re great she answered” She was calming down. No more wheezing.
“Are you sure?” I continued.

And she nodded. We continued our conversation. I was trying to make as many jokes as I could, this was definitely working.

Within two minutes even the non-rebreather was off, the legs were crossed and we were having a nice little chat. No more wheezing.

“What causes this I asked her?” She didn’t know. She’s been to therapy, is on medication and still she’s been intubated five times. We talked for a while, no wheezing, no intubation, no blood gas. Just words. She began to breath normally because we were talking.

I went home happy that night. And that’s why I became a doctor.

This week's Rounds

Go check out the best medical writing of the week.

Grand Rounds

This week's Grand rounds are at the Examining Room. Charles has been doing so many carnivals you'd think he put a picture of a ferris wheel somewhere on the page.

Hail To The Chief

Two days into my rotation as ER chief. That means that every patient who walks/is wheeled into the Emergency Room has to be seen by me first and then I hand it out to a junior resident.

“What part of Emergency did you not understand?”

Shame on you! You probably tuned in to hear me bitch about how bad Emergency Medicine is. Me, complain about the Emergency Room? You must’ve been reading another blog. Now wait here while I go fetch this guy a clean catch, I need urine.

“This is a level 1 trauma center. What level would you rate your arthritis pain and do you believe it really belongs here?”

I walk into another room as the twenty year old patient in the paper gown informs me I should remain quiet. “We’re in grave danger” he says. “I need a one-to one here” I announce to one and all as I storm out of the room to intubate the asthma exacerbation next door. Figures! He suffered blueberry poisoning last month and his parents tried to have him killed, in Europe, when they found out he was a double agent for the Israeli’s.

“I say Mazal Tov my dear friend. Please don’t let the door hit you on the way to the Psych ER” “And stay away from those blueberries”

The first day I was ill prepared. Guess what? It can get pretty busy here. Handoff rounds were of the brutal/ugly variety as I try to remember who these patients are, why they came and how old were they. I went with a ballpark figure.

“Senior citizen man here for pain in the abdomen”, “No, I have no idea, ask the junior what he found.”

The shift was over. I felt like I’ve been raped. Yes, I know this isn’t funny.

“Let me introduce you to the medical clinic. Sorry you waited so long in the waiting room but you see this building next door? You could have seen a doctor there ten hours ago in walk-in.”

Why the long-face? Did you not appreciate the Lumbar Puncture I did for your perfect tension-headache?

I love Emergency Medicine.