Merry Christmas, 2007!

Merry Christmas everyone!

I hope you all got what you wanted!

-AMiB

It's that time of year...

So, Christmas break is just around the corner (finally)! We third years have our last lecture of the semester (and technically, our last lecture of St. Andrews) tomorrow. We're all quite excited.

Today I spent the afternoon giving tours of the Bute to prospective students who have just been interviewed. I've done this a number of times, but today was more fun than I remembered...can't quite put my finger on why, but oh well.

I'm leaving for home Saturday morning. By Saturday morning, I mean my flight leaves at 6.30am. Which means I have to be there at 4.30am. Which means I have to get a taxi out of St. Andrews at 3.30am. Thank goodness I know a bunch of people who are on the same flight, so instead of paying the £50 myself, its down to £12.50. I'm quite looking forward to going home though, especially since none of my clothes seem to fit me anymore, and I'm excited to get some new ones.

Anyway, I really need to finish some more work before I go home. The plan was to be caught up and have all my notes, etc, done before I left. We'll see how that works, since I have a mandatory Skills Practice from 9-10am tomorrow, and a lecture from 12-1pm. And I haven't even started packing yet. Hopefully things will be fine.

Just felt like I should do a quick update, sorry its such a random dissociated post.

Only 5 more days till Christmas!
-AMiB

Twenty, eh?

20

This is one of the more..."interesting" meme's I've taken, yet the questions/responses are still quite amusing.

How many can you handle?

-AMiB

How fitting...

Which Action Hero Would You Be? v. 2.0 created with QuizFarm.com

You scored as William Wallace The great Scottish warrior William Wallace led his people against their English oppressors in a campaign that won independence for Scotland and immortalized him in the hearts of his countrymen. With his warrior's heart, tactician's mind, and poet's soul, Wallace was a brilliant leader. He just wanted to live a simple life on his farm, but he gave it up to help his country in its time of need. William Wallace 83% James Bond, Agent 007 67% The Amazing Spider-Man 67% Maximus 67% The Terminator 67% Neo, the "One" 54% Batman, the Dark Knight 54% Indiana Jones 54% El Zorro 50% Lara Croft 42% Captain Jack Sparrow 42%

Clinical Medicine Module: Cardiology

So, today was the second clinical attachment for me, the Cardiology attachment (I got to pick this one, and since I quite like Cardiology/Cardiovascular system, I picked it). I was pleasantly surprised to find that it was in Kirckaldy instead of Dunfermline, as the latter is an extra 20 minutes out. On arrival we went up the Education Centre, and then were forwarded on to the Cardiac Care Unit. 6 of us went with each Consultant (and switched halfway through). It was in the same general format of the Surgery Rotation, except more about heart failure and acute MIs. It was pretty interesting, and since I've always tried to be on top of my game on cardiac issues (since we see so many flowing through the ER), I was pretty on my game. At one point (after I answered that the treatment for a axillary vein blood clot s/p pacemaker placement would be a LMWH e.g. enoxaparin), the Consultant joked about "when I could start". It kinda made me feel like all those [unpaid] hours at the hospital really paid off. Bit of a confidence booster, if you will. The first consultant mainly dealt with cardiac causes of dsypnea as well as heart failure. He then showed us echocardiograms from the patients we had seen - I had never actually been taught what to look for, but he did a very good job at giving us a brief intro.
The second consultant took us to see a patient who had had an acute MI, was stented (I believe), and due to a bradyarrhythmia had a temporary pacer placed. Then after a bit of ECG review, we were let go.

Overall, I enjoyed it a lot more than the Surgery one, maybe because I've always leant toward Cardiology as a possible career choice...who knows?

In other news (one of which is semi-related to today):
Over the past few days i've seemed to develop a URTI. Most probably viral, and I'm trying to get through it. Got myself some Halls cough drops and some dextromethorphan/pseudoephedrine cough syrup, and it seems to be working pretty well. Also, today I decided that since I always get so nauseous on the bus to our attachments, that I would try one of the hyoscine(/scopolamine) tablets that I have. Now, I've never needed to take this kind of thing before - usually I just deal with the nausea - but I figure hey, why not? The whole bus ride went fine - we got to the hospital, and I figured everything was gonna be good.
Then I stepped off the bus. Immediately I could tell something was wrong. I didn't seem to be able to walk straight, my eyes were...funny. They weren't blurred, everything was just so...different. Not really sure how to explain it (well actually I do, we'll get to that later). However, I continued on and we all headed to the Education centre, Cardio floor, etc. The whole first hour or so, not only was I coughing up a storm, but I was having trouble speaking (bit of dry mouth?) and just coordinating in general. Things got better, over time though. So, hyoscine is an anticholergic - loss of pupillary constriction due to imbalance between para&sympathetic systems lead to the weird vision (must've had huge pupils - letting in a lot of light). Dry mouth is an anticholinergic side effect as well. I was trying to remember the rhymes for anticholinergic overdose, but all that came to mind was "Mad as a Hatter", and I sure as hell wasn't seeing things or grasping in the air - so I figured I'd be ok. It slowly drifted away, but I still feel kinda funny...hopfully it'll wear off by tomorrow.

And, in OTHER other news, I got a 17 (on the 1-20 scale that our Uni uses) on my midsemester assessment! (that's the lowest mark of a 1st class). Seeing as how I've never been able to get higher than a 15, I was quite happy. Except I know it was only because I did well on 2 questions that most others were fairly unprepared for...just means I'll hope to keep it up in the end of semester exam!!

-AMiB
p.s. it still freaks me out every time my sitemeter shows someone from within the University viewing my page...lol

Happy Raisin Sunday, 2007!

Happy Raisin Sunday!

Raisin Sunday is a tradition here at St. Andrews that has evolved over the years...
Rather than type out the traditions, etc, I am stealing the article from The Sinner:

Raisin Weekend is centered around the unique St Andrews tradition of the "academic family".

Each first year (or at least those who choose to take part - it is not compulsory) is adopted by an academic mother and academic father - who are usually, but not always, in their third or fourth year. In one form or another, Raisin Weekend has been around since the very earliest days of the university. It was, and still is, a "rite of passage" for new students.

On Raisin Sunday, first years spend the day with their academic parents. First of all, they attend a tea party with their mother at which, traditionally, not much tea but a great deal of alcohol is consumed. Later, the children are collected by their fathers and the evening is spent in the drinking of yet more alcohol.

In return for their parents' kindnesses, the first year is expected to give them each a bottle of wine. This is deemed the modern equivalent of a pound of raisins (actually, the modern equivalent of a pound of raisins IS a pound of raisins) which was the usual gift way back in the mists of time when students had a bland diet (has this changed much?)

On the following day (handily called Raisin Monday) and after being woken up, sobered up, cleaned up, and dressed up in outlandish clothes, freshers are presented with their Raisin Receipts. These are written in Latin and is a way of acknowledging the gift of raisins. They always used to be on parchment. Nowadays, almost certainly, the receipt will be something large, embarrassing and cumbersome which has to be carried around.

The gift-giving does not end here. Academic mothers give each of their children "Raisin Strings" with a small gift attached. The gift or "favour" is supposed to reflect the personality of the child. The number of Raisin Strings depends on the status of the mother. It is one string per year of matriculation - blue for first year, crimson for second, gold for third and black for fourth. These strings, with gift still attached, will eventually be tied to the child's gown hooks.

After all this largesse, children are paraded through the town until they arrive at Sallies Quad. En route, third years, fourth years and graduates of the university (if they are wearing their gowns) can stop any fresher and examine their Raisin Receipt. If they find a mistake in it then they can demand that the Gaudeamus be sung as punishment. Once at Sallies Quad, between 11 and 12 o'clock, a foam fight nearly always breaks out - it's almost traditional. The striking of 12 o'clock means the end of the fun for another year, and sees students slowly drifting off. Parents perhaps to have photos developed. Freshers, almost certainly, to sleep.

So, there you have it. Last year I had 20 children, 10 sons, and 10 daughters (no I did not pair them up, although Academic Incest is widespread within the University) - this is allowed since Medics are technically one year ahead - we do a 4-year degree in 3 years, so in first year we are taking 2nd year class, in second year we're in 2rd year, etc...

It was a lot of fun, but this year as Big Grandpappy AMiB, I will be party-hopping, trying to enjoy myself while making sure no one dies from alcohol poisoning.

-AMiB

Happy Diwali!

Happy Diwali, everyone!

It's pretty hard for me to celebrate by going to a mandir, since the nearest ones are in Dundee (which seems to always be closed) and Edinburgh, and since this coming week is Reading Week and all, I'll be pretty busy preparing for my Mid-Semester Assessment (which counts for 25% of my module mark - the other 75% being from my End of Semester Assessment).

Oh yeah, and I also got allocated to Preston, which I have a lot to write about, when/if I have time.

-AMiB

Happy Halloween!

That was me as a kid lol (not really...but it easily could have been). Tonight our Hall of Residence is having another Halloween party, and since I'm now on the Committee (Overseas Rep), I get to serve the alcohol for the first two hours. I can hear the American readers now - "your dorm GIVES you alcohol?!" - but it does me no beneift (except maybe on my ABC-assessment/BLS skills lol), since I'm teetotal. But that won't stop me from having a good time (never does). This year, I'll be taking the medic's "easy way out" of a costume, and wearing the scrubs I uhh...'borrowed' from my hospital back home, my lab coat (used only for dissection here, which is why it's currently in the washer), and my stethoscope. We'll see how it goes.

I leave you with this:


Happy Halloween, everyone! Be Safe!

-AMiB

I love work! :-D </sarcasm>

So, as Week 5 begins, I'm starting to freak out more and more. We have 12 hrs of class this week, and 14 next week (both less than normal), and then Week 7 is our University-wide "Reading Week". I don't really know why they call it that, unless for us medics. Everyone else in the entire University goes traveling or drinking (more than they already do during term) or home or something. The medics? We lock ourselves in the library/study/computer rooms and "revise" everything we've "learned" in the past 6 weeks.
Then Day 1 of Week 8 is our Mid-Semester Assessment, which counts for 25% of our module mark (the other 75% being our End-of-Semester Assessment). Then we continue on with our busy schedules until Christmas Vacation, which is a 2 week break spent - you guessed it - studying! Because exams are a week after that lol. I shouldn't really be complaining though, from what I hear they have it a lot harder back home, both in terms of workload and continuous assessment.

Alrighty, time to get back to it, I guess. Sedatives and Anxiolytics! Maybe I need some of those...

-AMiB

Good Day

Every so often, a day comes around that is just...good. Today was one of those days. Allow me to explain:

8.30am - woke up, had breakfast
11am - started the 2 lectures for today (Pharmacology - Neuroleptics and NeuroPhysio - Learning and Memory)
1pm - lectures finished, hop on over to the Union for AsianSoc meeting. everyone is pumped about BINDI·, including me.
2.30pm - got home, wrote up both lectures from today (completely ignoring the fact that I am behind on 11 or so anatomy lectures)
5pm - go to gym. Back and triceps today, and since the whole routine for today only takes 45 minutes or so, I had time for some Cardio (rowing machine) as well. burned a lot of calories, says my bodybugg.
6.15pm - Dinner. not the best, but whatever - its New Hall food, so yeah.
7.30pm - Prepped for Dissection tomorrow. Not as much as I should have, but enough to answer a few questions so they don't think I'm retarded, but not enough to be considered too "keen" (lol love that.)

I played World of Conflict for a little bit, chatted with some friends, and will be headed over to a friend's to watch the latest Heroes and CSI Miami.

Even had time to write a blog post. Awesome.

-AMiB

Clinical Medicine Module: Surgery Rotation

So last Thursday was my Surgery rotation as part of the Bute's new Clinical Medicine Module. We're basically the guinea pigs for this, but at least most of the kinks from last year's class had already been worked out. It was basically what I imagine an Introduction to Clinical Medicine class would be like if I were back home. There were 6 of us, and one Consultant (an Attending, back home), and we basically just went on a small Ward Round. He would explain to us basic things, do a lot of basic science pimping, as well as explaining some more of the semantic things about patient care (DVT prophylaxis with LMWH and stockings, etc).

For those of our class who have no/little hospital experience from a patient carer standpoint (eg doctor/nurse, as opposed to clerk), I think it was very beneficial. I'm not trying to sound cocky, but most of the stuff he told me I learned this past summer with the Hospitalists. However, he did show me how much basic anatomy I had forgotten over the summer/past year.

Overall I think it was pretty good, and while I was really looking forward to my A&E day next sememster, it turns out that it's just a ortho fracture review...but the Consultant offered everyone some Saturday night shifts in the A&E doing proper work, so I might just...pretend I have already met him and take him up on the offer :-)

In other news, I am very behind in my work. We have mainly only had Anatomy lectures so far (Head & Neck, and CNS), with a little bit of Pharm (General Anaesthetics, etc) thrown in for fun. I have written up 3 of the 15 lectures we've had, and more start tomorrow....*sigh*. That's med school for you...


-AMiB

Update...

OK, so I really have been neglecting my blog lately, which is probably why my visitor count has slowed to a trickle...

We are currently studying the anatomy of the Head and Neck, and I am sitting here trying to write notes, but it just turns in to me re-writing the book onto pieces of paper...not the most efficient method, but I can't seem to think of any other way right now...we'll see if it helps or not.

Out school as recently implemented a new clinical attachments scheme for the 3rd years (that's us!), so this coming Thursday I will get a 3-hr attachment with a Consultant Surgeon and his colleagues/team. I'm not really sure what to expect, or how much I'll get to do/learn in 3 hours, but it should be good and I'm quite looking forward to it. I also get a Cardiology attachment on the 29th of November, an A&E (ER) attachment sometime next semester, and another one of my choice next semester (hopefully Respiratory, it sounds fun).

Alright, that's the update, time to get back to the work. A friend is making a [Canadian] Thanksgiving dinner tonight (Canadians have theirs a lot earlier than we do), so am v. stoked for that - sorry, that was the 19 year old in me speaking.

-AMiB

Back in St. Andrews...

So I made it back to St. Andrews last night, and am currently involved in orienting Freshers (first years) to our Hall of Residence. Posts will probably resume once Fresher's Week is over.

Funny Quote from a Neurosurgeon a friend was working with over the summer:

Neurosurgeon: "And what should the patients [lab value] be?"
Intern: "Umm...I'm not sure"
NS: "Well f'ing guess then!"
Intern: "Umm...50??"
Neurosurgeon: "NO! There is no guessing in Neurosurgery!!"

-AMiB

Leaving, on a jet plane...

Cliche title, I know. Anyway, tomorrow I start the ridiculously long journey (like 23hrs total travel or something) back to St. Andrews. I should arrive at my hall at around 6ishpm GMT time (and have a meeting at 7pm. Great..)

I will continue my "What I Learned" series when I get back. For now, I must pack, get ready for Fresher's Week, etc.

-AMiB

What I Learned This Summer, Part 2

• When treating DKA, you cannot stop treatment before the bicarbonate has been corrected (~22-24)
• When a joint is inflamed, always feel the temperature - Warmth could be significiant of a septic joint
• When doing arthrocentesis of the knee, find the bottom of the patella, and go medial OR lateral (Dr. A thinks lateral is better)
• 7 Causes of Monoarticular Arthropathy
1. Septic Joints
2. Gonococcal Infection
3. Gout
4. Pseudogout
5. Bechet's
6. Trauma
7. Reactive Arthropathy
• Gout
• no need to tap if suspected in 1st metatarsal
• uric acid crystals found on microscopy
• 90% due to under-excretion of uric acid
• 10% due to over-production
• either way, Rx is NSAIDs + steroids
• in over-production, add allopurinol
• Pseudogout
• Calcium oxalate crystals
• Tx is NSAIDs and steroids
• Septic Joint will have >50,000 WBCs on microscopy
• True Iron deficiency shows low iron AND low iron saturation
• For the first 2 weeks s/p Acute CVA, allow for autoregulation of BP, except in hemorrhagic stroke
• AIDS
• CD4+ < 200 =" AIDS
• CMV Retinitis
• Toxoplasmosis
• Esophageal Cadidia
• TB
• MAI Reccurent
• Kaposi's Sarcoma
• Cryptosporidium
• Lymphoma
• General wasting, CD4+ count
• AIDS --> treat
• CD4+ < 350 =" treat
• CD4+ 350-500 = treat if >60,000 viral load
• CD4 >500 = don't treat
• If HAART works after 8 weeks, viral load should be gone
• If viral load is still present, they are resistant to part/all of the regime
• Geno/phenotyping to help determine what anti-virals to use
• Most common cause of Pulmonary HTN that is not easily explained is a chronic pulmonary embolus
• DVT's below the knee = no treatming
• DVT's above knee = Coumadin (warfarin)
• Recurrent DVT's = indication for continuous anticoagulation
• Best place to look on 12-lead EKG for A-Fib are in the inferior leads - II, III, aVF

What I Learned This Summer, Part 1

So, since I spent most of this summer prancing around the hospital in my shirt&tie or scrubs, pretending to be important, I decided I should have something to write down all the little tidbits that I pick up. Many of them are clinical "pearls", some are things that I just wrote down off of UpToDate (I mean uhh...my Attending stated it to me word for word, cuz stealing would be a Copyright Violation:-/), and some are just random things that a normal medical student would know that I didn't (aka the answers to pimping questions). So I decided it would be fun if I shared them with you. I've got 1 and a quarter (guesstimate) little shirt-pocket notebooks filled with info, so it make take more than 1 post. So without further ado, here we go:

• After every 6 units of blood, Calcium must be administered to help the clotting cascade.
• Consequences of Erythropoietin
• High BP (HTN)
• Seizures
• In Endocarditis,
• Janeway lesions --> no pain
• Osler nodes --> pain
• CLUBBING Acronym for causes of Clubbing
• C - cyanotic heart diseasse/Cystic Fibrosis
• L - lymphoma
• U - ulcerative colitis
• B - bronchiectasis
• B - bronchogenic malignancy
  
• I - idiopathic pulmonary fibrosis
  
• N - neoplasms
  
• G - granulomatous diseases
• Part of DDx of BRB in Stools:
• Diverticular bleed
• Aterio-venous malformations
• not too common
• usually in lower GI
• MMSE (Mini-Mental Status Exam)
• out of 30 points
• 28-30 = probably not demented
• 25-27 = borderline
• <25>
• ~13% of >75yo's have a MMSE <25
• Absolute Indications of Dialysis
• Pericarditis
• Fluid overload
• HTN
• Uremia
• N/V
• Creatinine >12 or BUN>100
• 2 Major Abx that cause Antabuse-like reactions when taken w/ alcohol
• Metronidazole (Flagyl)
• Isoniazid
• When UTI culture shows Proteus Mirabilis, a urea-splitting organism, investigations for staghorn calculi (e.g. Renal US) must be performed
• NEVER use Levaquin (levofloxacin) when pt is on Coumadin (warfarin) - raises INR dramatically (=bad!)
• Bicipital tendonitis - hold arm to chest wall; with flexed elbow, rotate humerus laterally while palpating the bicipital tendon (where bicep originates in shoulder) - if inflamed, will cause intense pain
• Pancreatitis (elevated Lipase) + Elevated ALT = Gallstone Pancreatitis
• 3 Leading causes of cough:
• Post-nasal drip
• Asthma
• Acid reflux (GERD)
• Pneumonia (PNA)
• crackles/rales
• CXR lags 3/4 weeks behind clinical (fever, O2 Sat, etc), even after pt feels better
• BUN more specific on CMP for PNA
• Put on abx: macrolide, 3rd generation cephalosporin, and broad spectrum flouroquinolone
• Septic Joint/Nongonoccocal arthritis is sometimes the presenting complaint in Infectious Endocarditis
• Causes of Macrocytic Anemia
• Reticulocytois (reticulocytes are macrocytes)
• Alcoholism
• Liver disease
• Interference with DNA synthesis
• Folate or Cobalamin (B12) deficiency
• Drugs e.g. hydroxyurea, methotrexate, etc
• Myelodysplastic syndromes
• Hypothyroidism
• Hyperlipidemia
• When Increased Creatinine or ARD is due to drug rxn, urine may contain eosinophils - test for them
• When alcoholic patients develop constipation, they develop hepatic encephalopathy - treat with lactulose to move bowels, and thiamine/multivitamins (e.g. banana bag - though these aren't used too much anymore)
• Pts with chest tubes/drains must be outputting 100mls or less over 24hrs before clamping off tube
• 6 Cardioprotective Agents
1. Statins
   
2. ACE-I/ARBs
3. Heparin/Lovenox (enoxaparin - an LMWH)
4. ASA (aspirin)
5. B-Blockers
6. Thrombolytics/TPA
• When dialysis patients get very itchy, its usually due to uremia
• Hypercalcemia can be secondary to malignancy - both solid tumours and leukemia
• 10-20% of cases are due to this, especially Breast & Lung, and multiple myeloma
• Occurs through:
• osteolytic metastases w/ local cytokine release
• tumor secretion of PTH-related protein
• tumor production of calcitrol
• Procrit (Epoietin) contraindicated in sickle-cell patients - does not differentiate between sickle cells and normal cells, so more of both are made (=bad!)
• In new-onset Type II Diabetes Mellitus, when trying to determine whether to start insulin or oral agents, use a fasting blood glucse of ~400 (mg/dL NOT mmol/L) as a barrier
• Below, use oral
• above, use insulin - but remember, insulin has side-effects!
• In pregnant DM patients, DO NOT use oral medications - insulin only!!
• When I/O is negative (down), you expect H&H to go up (less blood, more cells). If it goes down, check for active bleeding
• Esophageal Spasm, which can cause CP & mimics AMI symptoms can also be relieved by NTG
• AST + ALT in 1000's = Toxic (eg Tylenol OD)
• Normal AST/ALT with Increased Bili = obstruction
• Nitrofurantoin (Macrobid)'s major side effect = Irreversible Pulmonary Fibrosis
• Intracranial HYPOtension Triad:
• MRI showing sagging of the brainstem
• Bilateral subdural hygromas
• Diffuse dural enhancement
• Bronchiectasis (chronic infection of bronchi and bronchioles leading to permanent dilatation)
• Causes:
• Cystic fibrosis
• reccurent PNA
• immunocompromise
• Major bacteria:
• Staph Aureus
• Pseudomonas Aeruginosa
• Antibiotic most likely to cause C. diff infection - Clindamycin
• Can Flagyl (metronidazole - Rx for C. diff) cause C. diff? Yes.
• DVT's below the knee don't need treatment
• Pts on Metformin who are undergoing contrast studies need to hold Metformin for 48-72hrs after contrast administration, while monitoring BUN/Creatinine
• Do not enema/colonoscopy a pt with diverticulitis - you will perforate their bowels.

And with that, I will leave it till next time (it's late, whatever). If you have any questions/clarification, feel free to comment (I feel like I haven't been getting enough comments lately :-D)

-AMiB

Neonatal Opioid Withrdawal

3 day old AAM presents to the Emergency Room (at 2am) with agitation, excessive suckling, inability to sleep, etc. Upon further questioning of the Mother, we discover that during the last few weeks of the pregnancy, the mother was taking Percocet (and not small dose either, the 10/325 kind). Was discharged from the hospital today, fine.

After a little while, baby starts having seizures, etc. Scored an 8 on the Neonatal Abstinence Scale (although the NICU nurses determined he was a lot worse than that). Admitted to NICU (Neonatal ICU) for Neonatal Opioid Withdrawal. Treatment is Supportive care, except in cases of seizures, inability to sleep, and some other things (forgot to write it down off UpToDate).

Now, I'm not going to pass judgement on the mother or the condition of the baby...but, y'know, feel free to comment.

-AMiB

"Going to the ER"

Part 1:

http://www.youtube.com/watch?v=k9m2FLHlEwA

Part 2:

http://www.youtube.com/v/UM-HWkbnDfg


Thanks to ERnursey

So, it's been a while...

Well, I know it's been quite a while since my last post (which was featured in a Grand Rounds [only the second time I've submitted a post]). Things have been busy, I have been doing some steady 6-day weeks at the hospital and 5-6 day weeks at the gym. Am finishing up now, was in the ER today, have one more shift with the Hospitalists tomorrow as well as a night shift in the ER tomorrow and Saturday night. Then it's a few days of relaxation until my return to St. Andrews!

Couple interesting things I saw today:

86yo M on Coumadin bit his tongue 2 days ago, hasn't stopped bleeding since. Dr. M (female ER doc) puts a single 4-0 Vicryl (absorbable suture) in the hole, and applies some gauze. A little while later, patient has still not stopped bleeding, so we put some gel foam (little pieces soaked in thrombin/fibrin) to help the clotting...the bleeding slows, but the patient is poorly complaint (retired psychiatrist, Chinese - not much English) and it takes 3 things of gel foam and a small piece of surgicell to get it to stop. INR was only 2.0, btw.

64yo F originally from Northern Ireland on Vacation, forgot both her insulin refills and her glucometer. Felt horrible (very compliant in past, never forgot insulin shots ever); we thought it would be an easy script, but turns out her sugar is 501. We give her fluids and some insulin, but she doesn't understand what 501 is. Then I realize - in the UK we do blood sugars in mmol/L, while in the US its mg/dL. So, here is something for all you guys out there who encounter this problem: 1 mg/dL = 0.0555 mmol/L. So if you find her BS to be 501, tell her it's 27. If she tells you she's normally 5-8, that means she's normally 90-144. Hope that helps!

Today was also my last day shift in the ER...it always happens that I have to leave just when the nurses/techs/docs are getting used to me being around and are starting to feel more comfortable letting me talk to pt's, etc. Oh well, I've got years of that left.

-AMiB

Nail guns...

Man working with nail gun.
Man shoots nail gun (on accident) through great toe.
Man admitted to hospital for surgical removal of foreign body and debridement.

Always feels good to know that my profession is the one that fixes these people, not the one that it usually happens to.

Quote of the Day, August29th, 2007

Patient is admitted for cardiac/renal problems. She is known to be very non-compliant (had a transplanted kidney from a family member that failed because she wouldn't take her meds), and Dr. S has had this pt before. Patient has a history of seizures. At discharge last time, Dr. S prescribed Dilantin (phenytoin), an anti-seizure medication.

Dr. S: "Are you taking your Dilantin?"
Pt: "No, doctor, because I stopped shaking..."
Dr. S: "Who told you to stop taking your Dilantin?"
Pt: "No one doctor, I just stopped"
Dr. S: "You can't just stop taking your medication...especially ones for seizures"
Pt: "But I'm not shaking anymore, doctor..."
Me (in my head): "Yeah, you're not shaking anymore 'cuz you were taking Dilantin!"
Dr. S: "Are you driving?"
Pt: "Yes."
Dr. S: "AMiB, go grab me a DMV reporting form"

So people out there - if you want to stop taking your meds, no matter what kind, PLEASE, for our safety and yours, ASK your doc before doing so!

"Code Blue, 6West, Back Hallway"

So last night I was doing an overnight in the ER, and I had my first code of this summer. I've seen 5 or 6 in the past, and participated in 3 or 4, but this is the first one since I started at the hospital this June.

Dr. M (ER doc), the ER tech, and I, all head out of the ER and towards the elevators. We are met there by 2 ICU nurses and 2 Respiratory Therapists. We get up to the 6th floor, and head to the 'back hallway'. As we walk through the nurses station, I'm completely surprised as to how empty it was. They must all be with the Code, I figured. And I was right. As we enter the hallway, I see a scramble of nurses, frantically doing things to save the old man on the floor. I ask for the story, and try and see his face to see if he was one of ours (on the Hospitalist service - he wasn't). He's had had a couple stents placed this morning, and had seemed to be doing fine. He was taking a walk (who goes for a walk at 3.15am?!) with his nurse, when he started to feel faint, brady'd down, and collapsed. No pulse, no respirations - so the Code was called. After a couple rounds of CPR and drugs, we get him onto a bed and into a room. It was then that I realized how many people respond to a code. Roughly 30 nurses, techs, CNAs, 1 doc (which should've been 3 - the ER, the Intesivist, and the patient's Cardiologist), and a handful of Respiratory Techs.
I was standing outside at this point, and couldn't see much of what was going on. I did hear the patient, however: "GET OFF ME! YOU'RE KILLING ME! LET ME GO! LET ME GO!" (we were holding him still while trying to start an IV). These words were masking those of the Respiratory Tech: "Calm down, sir. Your heart stopped and we've had to CPR on you!"

Eventually, he stabilized, and Dr. M went off to talk to the patient's Cardiologist. He didn't feel much like coming in to write orders, and wanted to send his NP to do it. Now, I have nothing against NPs, but if you're a Cardiologist, and you cath'd someone this morning, and they Code: come in. What about the patients family? It's your responsibility to let them know what happened. But anyway, I digress.

By now, he's lost his pulse again. On with the compressions. We secure the airway with endotrachial intubation. The patient kept fluctuating between PEA, Asystole, and Brady, all the way down to the ICU. We get down there and continue compressions. Dr. M puts in a femoral arterial line to see if the compressions are working, as well as if the patient's heart is beating on its own.

At 4.116am, roughly an hour after the Code was called, Dr. M pronounces the patient. The monitor is turned off, and everyone stops what they're doing. We look down at him, and see that his larynx is moving. Either he's trying to breathe on his own, or he's swallowing. Either way, that's not what a dead person does. We feel for pulses: one on each fem, one on each carotid. One of the ICU nurses swears she feels a pulse. Other people feel it as well, so we turn the monitor back on - but they don't match. It's much faster than what is on the monitor. I tell them to feel their own pulse while they're feeling the patients. Yep, those match. I guess it kind of goes to show how much health care professionals want to save their patients. We listen for heart sounds, check reflexes - nothing. His throat was probably just agonal breathing (last breaths).

Time of Death, 4.20am.

Quote of the Day, August 23rd, 2007

So there's this Infections Disease doc, Dr. C. The Hospitalists hate the ID guys, cuz they interfere with our antibiotic treatment and blocking discharges of patients who really should be going home. Anyway, I've NEVER seen Dr. C, but I always see her notes in our charts. For a while, I didn't believe she actually existed. Figment of our imagination, I believed. In reality, she rounds late at night, because her notes are always timed no earlier than 2200 (once, she had put 2430 - because they have to see each patient and write a note each day).

Anyway, today I actually met her. She looks up at me and asks me to question I get so many times -

Dr. C: "So, are you a new Hospitalist?"
Me: "No, I'm just a Medical Student"
Dr. C: "Oh...you're awfully big for a medical student"

wtf?!

15 hours?

So I just spent the past 15 hours in the ER...I think I coulda pulled off the full 18 hours (2 9-hour shifts with 2 different docs), but my parents don't take too kindaly to being gone for 18 hours at a time so I came home...

I really learn alot, and while the doc takes the history, I have started trying to guess their next question (which i'm horrible at) but also what tests they are going to order. I seem to always miss one or two big ones, but hopefully with time I'll get better.

Now please excuse me while I sleep for an unknown length of time.

Oh, how I miss it down here...

So ever since Dr. M (ER doc) gave up his overnight shifts, I've only been able to do 2 shifts a week with him in the ER. For a guy who has a semi-secret desire to be an ER doc, this is not enough. So tonight and [hopefully] tomorrow night, I will be doing some overnight ER shifts with Dr. M (a different one, who happens to be the only lady ER doc that we have). It should be exciting, especially since tomorrow is Friday night, and we're a Level II Trauma Center, meaning we get all the drunk fights and car accidents for 1/4 of our city.

Bring on the energy drinks!

-AMiB

An Example of Poor Doctor-Patient Interaction...

http://www.ctrlaltdel-online.com/comic.php?d=20070815

Quotes of the Day, August 14, 2007

Cardiothoracic Surgeon's NP: "Ugh, I can never get any nurses on that floor to answer their phones!"
Secretary: "What happened?"
NP: "Well this time, I got transferred to another nurse because the nurse I wanted to talk to was stuck in a Code Brown!"
Me: *stupidly looks down at badge, flips through different codes; finds no Code Brown* "What's a Code Brown?"
Dr. A: "Hahaha, you've never heard of a Code Brown?"
Me: "Noo..."
NP: "I'm going to let you figure that one out by yourself."
Me: "ummm....OH!" *face-palm*
NP: "It took you that long? Are you sh*tting me? ;-)"

Quote of the Day, August 6th, 2007

OK, so I went for half a day this morning, but decided to take the rest of today and all of tomorrow off - half for my birthday, half because I've got a bit of pharyngitis going on.

Dr. R - So this patient is on really high doses of prednisone - 100mg daily, and she's been having some hallucinations.
Patient - Yeah, I keep seeing the Pillsbury dough boy...
Me - *tries hardest not to laugh*

-AMiB

AMiB, 19 year old

Happy Birthday to me,
Happy Birthday to me,
Happy Birthday dear AMiB,
Happy Birthday to me!

And of course, like any proper medic would do, I will be spending today at the hospital (with a short interval for gym training).

Have a great day, everyone! :-D

Pharmacist Respect

http://youtube.com/watch?v=sGip7x-sIuo

Possibly one of the oldest medical spoof videos I've seen...was sent to me by my dad - all you Pharmacists and Pharmacy students out there should appreciate it :-)

Peds (Paeds) Trick

Learned a little trick in the ER for when you have 3 year olds whose eyes you need to look into:
Make them watch you do it to their parent, who is holding them. Do exactly what you are about to do to them, then say "OK, now its your turn!" Seemed to work out fine for the 2 young patients we had today (thankfully one did not have the head bleed we were worried about).

-AMiB

Time of Death, 11:36am

So Dr. M had to call a patient today. This is the first time I've seen someone die on the floor (seen 3 or 4 in the ER). Was an 90something year old woman, DNR, had a mid-brain bleed while in a nursing home, was admitted officially for the bleed, but really so that she could die peacefully.

I never realized how much you have to do to pronounce someone. Pupils have to be fixed and dilated, no gag reflex, listen for 1 minute for absent heartbeat, absent Babinski's sign. Then there's the paperwork...don't get me started on that.

It was humbling, to say the least.

There is treason afoot...

There seems to be a lot of secrecy, treachery, vying for power and spying going among amongst some of the Hospitalists. It's kind of funny to me as an outsider, but it'll be interesting to see how this pans out...

I learn so much in 8 hours with Dr. A (medical director), it's kind of ridiculous.

-AMiB

QuoteS of the Day, July 23 2007

Dr. R: Have you had a bowel movement yet?
Little old lady, diverticulitis who hasn't had a bowel movement in 4 days: No...and they keep giving me stuff, but it doesn't seem like it's working
Dr. R: OK, we'll try some more lactulose...
LOLdwhhabmi4d: Lactulose?! They've given me so much of that, when I finally go it'll blow up the city!!

-------------------------------

At the rounds meeting, discussing one of the Neurologists who likes to call Infectious Disease consults when they aren't really needed:
Dr. R: Yeah, one time she called me because a patient had a scrotal rash
Dr. A: The question is why is a Neurologist looking at his scrotum?!


So, am back form vacation - was fun, but am now back at the hospital...oh well.

-AMiB

Quote of the Day, July 13th 2007

Went to a Quality Control meeting today with Dr. A, because he was on call today and is the Medical Director of the Hospitalist service. When discussing 30-day mortality from Pneumonia in our hospital:

QA Guy: "[Our Hospital] has the lowest 30-day mortality rate for Pneumonia in the state!"
Everyone: *claps*
Crit. Care Doc/Pulmonologist/Intensivist: "It's obviously over-diagnosis"
Everyone: *laughs*
Intensivist: "We treat heart failure with antibiotics"


Am leaving for vacation tomorrow, will be back in a week or so (as if I weren't behind enough on my RSS feeds already...)

-AMiB

Quote of the Day, July 5th 2007

OK, so I'm gonna try this new thing...it won't be every day, but every time there's something funny...like this :-D

Dr. R: "So, do you take anything for the pain in your leg, like Advil, Tylenol...?"
Little old lady with multiple medical problems (Hx of PE x2, s/p Stents x4, s/p IVC Filter, DVTs, etc): "No, I just take some little stuff...like Vicodin"

Since when did narcotics become so much like candy?! This lady is 83 yrs old, mind you...

-AMiB

Fireworks, as promised

For all of you who couldn't make it to see some fireworks this 4th of July, here are some so you don't feel left out:









I'm trying to upload a video of the finale using Blogger Draft's Video feature, but it doesn't seem to be working...oh well.

-AMiB

4th of July!

Happy 4th of July, everyone!

Pics/videos to come later

-AMiB

AMiB, Hospitalist Groupie. (and other stuff from a 12-hour day)

8am - Arrive at hospital, head to 7W. Dr. B, General Surgeon, is there seeing one of our patients. Funny story about that: We met Thursday when he and Dr. A were discussing the patient. Over the weekend, we went to a party for a family friend. I saw Dr. B, and and for a little while, I didn't recognize him - but then I did. Went over, talked for a bit. Turns out he went to a Uni not too far from mine, and now is practicing General Surgery at my hospital. Says that they'll be writing up the case, and wants to know if I'd like to help out and be published. To which I responded a calm, "Yeah, that'd be great." while inside thinking "HELLZ YEAH!!!". I don't want to get too excited now though, because I always do that and then things never turn out my way.
9am - Start with Dr. S, Hospitalist. Saw a lot of interesting patients. Can't remember any right know though. It's been a long day :-P
11am - Hospitalists Round meeting. As usual
12pm - We're waiting on a drug rep to bring us lunch. All of a sudden this guy from Boston Market comes in.
Boston Market Guy: I'm gonna need a place to put all this food.
Dr. A: Just use this desk.
BMG: Yeah....that's not gonna be big enough....
Dr. A: uhhh...seriously?
BMG: Yeah...well, I'll try.
BMG proceeds to take out large amount of food, including but not limited to: chicken, turkey, steak, corn bread, sweet potato casserole, vegetables, mashed potatoes, gravy, and chocolate chip cookies. It. was. amazing.
BMG then proceeds to tell us about a new use for an old drug, as well as 2 new drugs, which was useful, because we had a patient who needed one. We then scored a free pen and crazy-bright LED flashlight. Should I feel bad for being sucked in by drug reps? Probably. Do I? Absolutely not, lol.
1.45pm - Up on 4E, an amusing conversation:
Nurse (to me): So are you Interning or something? I always see you around with the hospitalists.
Me (to nurse): Nope, I'm just a student. I just follow whoever is on call and watch.
Dr. S: He is a trooper....He's like our groupie.
2.59pm - Finish with Dr. S
3.01pm - Head down to ER. Meet Dr. M, Emergency Physician. Ask to shadow. Start shadowing. I really missed the ER. Had 2 critical patients back to back, both were sedated and intubated using RSI. One was a drug overdose who started vomiting in the ambulance after Narcan administration, went into SVT. When I was leaving, they had tried cardioverting him with no effect. I think they tried some adenosine too, not sure.
8.35pm - Make the decision to leave (that's usually how it is in the ER, because once the new doc comes on, Dr. M stops seeing new patients).

Was quite an educational, eventful, and promising day. And now I am ridiculously tired, I still need to go on the treadmill, and I have to look up everything there is on the internet about SMA syndrome.

-AMiB

AMiB, ACLS Provider.

Whoo! I am now officially (for the next two years) licensed by the American Heart Association as an Advanced Cardiovascular Life Support Provider.



The class size was really small, so we got out pretty early each day. Was a lot of fun, because it was taught by a firefighter (young guy, been a fire medic for 8yrs), and he was pretty lax about it and made sure we did well and passed.



All in all, was definitely worth it - and now when it comes time to start residency or if I transfer or whatever and need an ACLS cert, all I have to do is the recert class.



-AMiB

Secondary Causes of Hypertension....GO!

24 year old Japanese male, admitted for HTN. In a guy his age, has to be a secondary cause.

DDx was as follows:

• Renal Artery Stenosis - ruled out: BUN & Creatinine were wnl
• Hyperaldosteronism
• Phaeochromocytoma - abdominal CT orderdered, as well a 24hr urine for VMA
• Coarctation of the aorta - ruled out w/ CXR
• a couple others that I can't remember

Patient also had raised ICP (papilloedema), secondary to a Colloid cyst; Dr. M was thining possible Benign intracranial hypertension (formerly known as Pseudotumor cerebri.)

So, as it turns out, the guy is just from Guam, where everyone seems to have high blood pressure. Pt's father died @ 40yrs from MI, all siblings also have HTN. So it was a simple familial/environmental thing, but as Dr. M put it, this is "real internal medicine; none of that 'when can we send them back to the nursing home?' stuff". I found it quite the interesting case. Didn't enjoy being pimped on the causes though (was one of our SAQs back in first sememster when we did CVS - didn't do so well then either lol).

Today's pimp question from Dr. A: Name the 6 classes/types of Cardio-protective drugs/agents:

1. ACE-I/ARBs
2. Beta-blockers
3. Statins
4. Heparin/Lovenox (LMWH)
5. TPA/Thrombolytics
6. ASA/Aspirin

(I was going to put links to all of them...then realized that I use wikipedia for everything, so you can look them up yourselves, if interested :-D)

In other news, ACLS class is tomorrow and Saturday. I should go prepare for that...O:-)

-AMiB

Ambulance Driver teaches cardiac conduction pathologies...

A hilarious yet informational post about normal cardiac rhythms as well as the different types of heart blocks...Sex, Relationships and the Cardiac Conduction System

"Pretty soon, despite all signals from Virginia that she ain't happy, Sidney has convinced himself that he is indeed the master of this relationship. He wears the pants. He's got a toupee, he's wearing the Mister T starter kit, he's driving a red Miata, and he's got a pneumatic little twenty-year-old secretary named Mitzi who giggles at all his lame-assed jokes and says things like "Ooooh Mr. Sinus, you are so cute! I just adore older men. They're so...experienced.""

Enjoy

Whew, that was a close one...

So we've had a patient for a while now, came in about a week ago for a acute exacerbation of chronic asthma. He seemed to be doing fine, so we discharged him late Thursday night. Friday morning at rounds, I find out that he was admitted at 4am that morning. ER complaint showed acute shortness of breath, the regular. But to the admitting doc, he complained of a small amount of abdominal pain as well. He's a pretty large guy, so the exam was negative. At the rounds meeting, we determined that he might be drug-seeking, and that we wouldn't give him any IV narcotics. The doc decided to do some tests and get a CT of his abdomen anyway, just to cover his bases. Defensive medicine, as it's called.

Turned out her had a perforated diverticulitis...that was a close one.

-AMiB

My last post about drinks...I swear O:-)

Mexican Jumping Bean. Oh..my...god. How did I not see this one before?! Instead of Vanilla and instead of Caramel, it's Mexican chocolate (that sounds like it would be a good nickname for the Mexico Medical Student...please let me know if you object :-D) and Hazelnut. There was also some powder strewn about in the cup, but I have no idea what it was (I'm pretty bad at recognizing flavors...I just love enjoying them:-P).

ANYWAY. We've been seeing a lot of Community-acquired Pneumonia recently. It's been getting the Infectious Disease guys pretty worried. Speaking of which, why the hell do we need an ID consult on every patient who has some type of infection? If Mrs. Random has a UTI and we decide to put her on some Levaquin, why should we have to wait for them to come and see her? Apparently some of the Hospitalists stopped doing this a while back, and they started bitching to the Chief of Medicine...whoops.

Memes Galore

(Thanks to keagirl of UroStream)

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Ooey Gooey Caramel

Today, I decided to go change it up a bit, and so instead of my Chilly Willy Vanilly, I went for its cousin, the Ooey Gooey Caramel. It's pretty much the same, but instead of vanilla flavoring, it's got caramel. And then the inside of the cup is lined with caramel syrup. And it tastes really, really good.

Just thought I should let you all know :-)

Auscultation, anyone?

Heard my first real, live crackles today. Was really awesome. Was my first time working with Dr. M, who is actually a really good teacher. When looking at labs, etc, he'll essentially just start saying out loud everything he is thinking, which helps me learn how to interpret them and such. Same with x-rays, and he explains things very well.

Did you know the BNP test is only like 5 years old? Before that, apparently there was no real way (besides clinical aptitude) to distinguish between pneumonia infiltrate and CHF edema in the lungs...

I really suck at making up title's for blog posts...

1,000

Haha, so I'm my own 1000th visitor. Only someone like me would do something like that...lol. Taking a page from the little medic's book, some interesting google searches that got me to this stage:
1. Urigrow. Fitting, as I posted the video online.
2. A&E manchester royal infirmary 2007
3. what to expect neck exam
4. EMT-B summer UK
5. ACLS PHARMACOLOGY (why all caps?)

I wonder what the next 1,000 will bring? (that's me being hopeful, there lol)

-AMiB

Because Cal tagged me...

Two names you go by:
AMiB
VeerTheTIGuy

Two things you are wearing right now:
Black shirt (kinda faded though - boo!) and grey slacks. Was also wearing a white with black/grey pattern tie. I got complemented on it ;-D

Two things you would want (or have) in a relationship:
haha ummm...
good times (e.g. lots of laughing)
lots in common

Two of your favourite things to do:
shadowing, apparently lol
driving my dad's bmw 530i

Two things you want very badly at the moment:
not to sound like a broken record or anything, but the opportunity to do some h&p's, start some IVs, etc.

Two pets you have had:
never had any pets. :-(

Two people you would like to do this:
i'm gonna take the little medic's route and say anyone who wants to.

Two things you did last night:
ooh, let's see if I can remember...
watched the daily show&colbert report
tried to catch up on my RSS feeds (and failing horribly...)

Two things you ate today:
umm...turkey sausages in the morning
a 7-layer crunch wrap that i put in the fridge from last night

Two people you last talked to:
my mom (oh snap, that reminds me that I need to call her - thanks!)
my younger sister (both on phone)

Two things you are doing tomorrow:
sleeping

Two longest car rides:
the rides to and from the airport usually seem pretty long, although it's only 2 hours or so
we've done some family road trips to many different states, so those were pretty bad...

Two favourite holidays:
ok see, we've got totally different definitions of holidays.
my answers would be Christmas and my birthday (which isn't really a holiday - but I get good presents for both :-D)
but if you mean VACATIONS, the cruise we took to the bahamas was fun, and going to paris with the st andrews crew

Two favourite beverages:
juice (particularly orange) - just ask my mom/sister, they yell at me about how much i drink
Chilly Willy Vanilly - just had one actually; they sell it in the coffee cart outside my hospital - sooo good! and great name, too :-)

Medical Specialty Aptitude Test

http://www.med-ed.virginia.edu/specialties/Home.cfm

Results
Rank	Specialty	Score
1	emergency med	42
2	orthopaedic surgery	41
3	gastroenterology	41
4	dermatology	40
5	occupational med	40
6	pediatrics	40
7	nuclear med	40
8	urology	39
9	aerospace med	39
10	general surgery	39
11	med oncology	39
12	family practice	39
13	ophthalmology	39
14	obstetrics/gynecology	39
15	otolaryngology	39
16	radiation oncology	39
17	nephrology	38
18	radiology	38
19	psychiatry	38
20	preventive med	38
21	thoracic surgery	38
22	neurology	38
23	neurosurgery	37
24	rheumatology	37
25	pulmonology	37
26	pathology	37
27	plastic surgery	37
28	endocrinology	37
29	cardiology	37
30	general internal med	37
31	hematology	37
32	colon & rectal surgery	37
33	anesthesiology	37
34	allergy & immunology	36
35	physical med & rehabilitation	36
36	infectious disease	35

Week 1, Part 2

Thursday:
8.30am - Arrived on 7W
8.35am - Dr. S arrives on 7W (first time I have arrived before a Hospitalist :-P); Rounding begins. This time, was equipped with my Sanford Guide (2003, need to get a new one), my PIMP Protector, and my sister's Oxford Clinical Handbook. All of which came in useful. We saw quite a number of patients, some of which who were very nice and polite, and others who were, as Dr. S put it, "bitches". I just smiled like a good little medical student :-). Let's see...notable cases: a lady with a new onset of back pain from an old L1 compression fracture, as well as an unkown pain in the mesogastric area of her abdomen. History of shingles (Herpes Zoster), coronary artery disease s/p 3 stents placed about 5 years ago, renolithiasis stuck in renal pelvis (but asymptomatic), an ovarian cyst, and rheumatoid arthritis. Dr. S orders a test for rheumatoid factor, ANA & ESR to see if abd. pain might be rheumatoid in origin; MRI of back to look for any possible new fractures leading to her back pain; MRA of abdomen to look for atherosclerosis of mesenteric arteries, possibly leading to abdominal pain. Was quite the interesting case. Dr. S called her a bitch. :-P
Saw a 90 year old lady with Alzheimer's, who had been prescribed sleeping medication q4hrs PRN. Nurse (at care facility) had given it q4hrs instead, as well as ativan (wtf, why?), and patient sort of just nodded off...for a few days. Was starting to wake up today, A&Ox1(name)
We were called for a consult on a young lady who had had gastric bypass surgery 3.5 years ago, and now is having abdominal pain. Bariatric surgeon went in, lysed some adhesions, but didn't find anything else that could be causing the pain. So called for a Med consult. We (and when I keep saying 'we', I mean Dr. S, with me following like a sheep...or a shadow :-P) figure it's an infected blind loop, and call for a GI consult to do endoscopy so we can biopsy the sac.

Finally asked Dr. A and Dr. S what they do after rounds, while waiting for consults. They say mostly the admits/consults pile up, so they don't really get a break. Usually lunch is their first stop, though.

Am looking forward to working with Dr. C tomorrow (she's the same race as me...always fun lol)

Friday:
8am - Working with Dr. C today. She only had 5 or so patients, but was on call. I just realized that me describing my day week after week will get boring after a while, so maybe I'll continue, maybe I won't. Saw some diverticulitis patients, lobar pneumonia (possibly community-acquired, possibly aspiration). Had my first (well, first with the Hospitalists) drug rep visit. Some nice ladies from the companies that make Lovenox (enoxaparin, a LMWH - low molecular weight heparin) and Lantus (insuline glargine) came in and brought us lunch (Sanofi Aventis, I believe). Apparently, Lovenox is now approved for STEMI patients. Fancy that. I got a free lunch and a pen and a clickie-sharpie, both with LOVENOX written on them. Awesome.

Got the weekend off (err...will take the weekend off?), and am working with Dr. C again on Monday, 8am.

Week 1, Part 1

Monday:
8.15am - Start 'rounding' with Dr. R, Hospitalist. See a number of patients she already had from previous days, so no full workups. Some interesting cases, including Acute Renal Failure secondary to Rhabdomyalosis after running a marathon. And a homeless patient who had been in hospital for several months (since February), who tried to drink his own urine. Twice. While IN hospital.
Only saw a handful of patients. Dr. R assured me that this is not the normal case, and she normally has twice as many.
Side note: She kept introducing me in this manner: "This is Dr. AMiB (well, my last name), he's actually a medical student who's shadowing me today." This got me confused, because didn't someone who went through a normal US school and residency have students with them on rounds, and know how to introduce them? I tried correcting her every time, but she kept doing it...i dunno.
11am - 'Grand Rounds' is what I'll call it, it was more a meeting, really. Went down to the Hospitalists office, met with the 2 other docs who were in hospital at the time, the Medical Director (also a Hospitalist), and the Case Managers from the different floors. Went over all the patients they had, and let the case managers know what is going on and what the plan of action and time frame would be. (Heard of a case of Necrotizing Fasciitis!)
After GR, saw a couple more patients, then Dr. R...left, the hospital. I was quite confused, really. I understand that being on call means coming in and admitting any Medical patient the ER decides to admit, but after rounds, what is there really to do? (At the time of this writing [Tuesday night], I have no idea what Hospitalists do for the majority of the day. I plan to ask tomorrow.) Hopefully I will find out or find something to do, because leaving at 12 after a few hours of seeing patients is kind of boring, really. Don't get me wrong, I enjoy the patients I see, but because I'm not allowed to go see patients by myself, should I just literally follow the doc wherever they go?! Most of them take care of personal things, or work on charting. This is time that could be spent wisely seeing interesting patients, but guess what?! Can't do that. (I'm not still bitter - I promise! :-P)


Tuesday:
7.15am - Arive in OR
7.30am - Dr. C, Neurosurgeon, arrives in OR
9.35am - After 2 hours or prepping the patient, first incision is made. The patient was an elderly gentleman, struck by an auto. He had a mechanical heart valve, and was on Plavix (clopidogrel), a commonly used anticoagulant. He had a broken shoulder, open tib-fib fracture, as well as pretty severe head bleeding (due to the Plavix). Also, he has a Type 2 odontoid fracture. His C1/C2 joint is unstable, and his C3/C4 joint has rotatory dislocation. Also, the facet joints all the way down his C-spine are opened/problematic. At the C6/C7 joint, there is subluxation and the thecal sac is endangered. He is 10 days post-incident, and Dr. C believes he is ready to have surgery. An Occipitocervical Fusion is performed, fusing the occiput of the skull all the way down through C7. Graft taken from the right iliac crest, as well as allograft bone marrow was put near the rods to hopefully fuse them. The patient will have absolutely ZERO range of motion in his neck, as if he were permanantely in a halo. I really hope they caught the guy who did this.
3.15pm - After nearly 6 hours in open surgery, and 8 hours in the OR, Dr. C starts closing and I head out. I had had an amazing vantage point, standing at the head of the patient, looking straight into the posterior cervical incision. Dr. C was to my right, and a Trauma NP was to my left, assisting. I didn't even have to scrub in, since I was on the non-sterile side (I hate being sterile, and would've died if I had to have been standing there for this long). All in all, was an amazing day. Not many people my age or in my class can say they've seen what I've seen, and while I bitch and moan about what I don't get to do, sometimes (like these), I realize how lucky I have been.

Wednesday:
8am - Started rounds with Dr. A, the Director of the Hospitalists group that does the Internal Medicine call for out hospital (the guys I'll spend most of the summer shadowing). Saw a number of interesting patients, most of which I can't remember at this time, except Necrotizing Fasciitis! Dr. Adrian says he hates that diagnosis, since it grosses him out, but as a student, I can't help but find it cool. So sue me (no seriously though, don't - I have no money, being just a lowly student! :-P)
Dr. A was an Attending at the same teaching hospital where he did his residency, and is very skilled in the way of Academic Medicine. He introduced me properly, as "AMiB, one of my medical students", and gave me my first real dose of PIMPing. For those of you not from the medical profession, here is a definition of pimping:

The term pimping is common slang in medical education to describe the process of attending physicians asking physicians-in-training (i.e. resident physicians or medical students) difficult questions — some would say just questions in general. This is usually used in a derogatory fashion by those being on the receiving end of questions, as in, "I got so nervous when Dr. Smith pimped me about the causes of pancreatitis!" According to The Art of Pimping by Brancati, German surgeon Walter Karl Koch first recorded "Puempfrage" questions in 1889 to be used while seeing patients with his students in Heidelberg. In America, Abraham Flexner noted on his visit to Johns Hopkins in 1916 that Osler (likely William Osler) used rapid-fire questions on his students.

And let me tell you - it sucked. I'm taking this as a sign of how little I know, although I believe Dr. A was asking me questions that I wasn't really supposed to know the answer to (the only one I got right was looking for splinter haemorrhages in cases of Infective Endocarditis). Wow, I just realized how overboard I'm going with these links. Oh well.
We had a few admits in the ER, including a homeless man in alcohol withdrawal and associated seizures, who chose to use the ER bathroom floor instead of the toilet to take a dump. How nice of him!
Also, a patient with renal failure, probably due to an unknown obstructive uropathy (wheee I love big words :-D), and a really nice lady with cellulitis of the arm.

Near 1ish, Dr. A told me he was going to step out for a bit, and to go grab lunch. He said he'd call me when the next admit came in. So I went to the Physician's Lounge, grabbed some of the free pastries and coffee they had there, and just sat and watched TV while I waited for a phone call. Eventually it came in, and we met up again in the ER. We admitted the cellulitis lady, went up and saw a patient who had been in surgery during morning rounds, and then that was essentially it. He said I didn't have to stay till 6, as I had probably seen plenty of good patients. I agreed, and said I would head home. But I kind of wanted to see what he would have said if I had wanted to stay the whole shift. Would I have just sat in the Physician's Lounge again? Maybe done nothing in their windowless office (it's in the basement, definitely not their fault lol)? I dunno. Will see when I go with Dr. S tomorrow. Apparently, Dr. A says that if I thought his pimping was bad, I just have to wait until Dr. S's. I'm a bit scared. Will bring my PIMP Protector with me!


OK, so I've decided to post this first half of the week, just to see if you guys like it, and just so you don't think HIPAA has dragged me off the face of the earth (which they may well do after this post! :-/) Please leave feedback in the comments, lettering me know if the style of the post is good. I thought that small, daily posts would have been too annoying, so decided to go for a Weekly one. If y'all think it's cool, I will probably continue like that for the summer. So...yeah. Here goes!

And so it begins...

Medical Student Observer forms filled out...check!
Immunization Records up to date...check!
PPD Tuberculosis skin test...negative! (that's a good thing)
Doctor(s) who are willing to let me shadow them...check!
Hospital badge so I don't get kicked out of the hospital...check!

So, looks like I'm all set! Once I get the go-ahead email, I'll head in on Monday for my first day. The shifts are 6am-6pm, but it doesn't seem like any of the docs start before 7 or 7:30. We'll see how long I actually last on the shifts, but I'm gonna try and stick em out.

Also, Dr. C is doing a surgery Tuesday morning that he's willing to let me watch, so I'll probably be in for that too.

We'll see how this all goes, I'm pretty much playing by ear as it is.

A Ray of Hope...

Looks like there may be some opportunities for me after all...not as much 'doing' as I'd like (or any at all), but I think at this point, having sat at home doing nothing for so long, I'll just be glad to get back into the hospital...

Wish me luck, have a couple meetings tomorrow to sort it all out!

-AMiB

ACLS

So I just got my American Heart Association ACLS (Advanced Cardiovascular Life Support) Provider course materials in the mail.

"Through the ACLS course, providers will enhance their skills in the treatment of the adult victim of a cardiac arrest or other cardiopulmonary emergencies. ACLS emphasizes the importance of basic life support CPR to patient survival; the integration of effective basic life support with advanced cardiovascular life support interventions; and the importance of effective team interaction and communication during resuscitation. "

More info here: http://www.americanheart.org/presenter.jhtml?identifier=3011972

Looks like there's a lot of work involved before the class actually begins. Better get to it...

Will keep you updated once the course starts (June 29th/30th) :-)

-AMiB

The Quest for Summer Medical Education

So, since I have 4 months of summer vacation, I decided I should do something more productive with my time than sit here and do nothing all day. Last summer I was taking a class to get my EMT-B license (Emergency Medical Technician – Basic; the lowest level of Ambulance training there is), shadowing an ER doc, let's call him Dr. M, at my local ER, as well as shadowing a neurosurgeon (actually, the Head of Neurosurgical Trauma), Dr. C (who should really be called Dr. Ridiculously Smart & Awesome…or something along those lines).

First, a bit of history:

Dr. M was the doc who was always on at the ER when I was doing my Volunteer shifts. When it came time to do my preceptorship in the summer before first year, I chose Dr. E (another ER doc), because he seemed 'cooler'. Bad choice. He is an amazing doctor and gets the job done, but I felt he could be quite rude, at points, and had a bit of a short fuse. To be honest, I'm kind of like that too, at times, which may be why when Dr. E went on vacation, I asked Dr. M if I could shadow him. Dr. M has been doing practicing Emergency Medicine for 30 years. He's a Navy guy, but is very relaxed and laid back, and tends to let the younger docs pick up more shifts, so he can have more vacation time (after 30 years, I'm sure I'd be doing the same). So I started shadowing Dr. M on most of his shifts, and he never seemed to mind. When I left, he said I could come back whenever, and I took him up on that when I returned last summer. The Medical Staff office has a short form you can fill out, defining yourself as a medical student, and allowing you to "Observe" a physician – essentially a shadowing position, exactly what I was looking for.

I was introduced to Dr. C by the Volunteer Coordinator, a nice lady who looks after the Volunteers. She felt that this would be a good fit, as Dr. C was new to the hospital, but was very eager to teach students. I started shadowing Dr. C in his office, which is in a Medical Office building on the hospital campus, and once I got the "Observer" status, I was allowed in the OR as well – he even taught me how to scrub in. He also said that I could come back this summer, but we'll get to that later. Funny story about my first day with Dr. C: I was going to his office straight from EMT class (class ends at 12, first patient is at 12.45). The hospital was only 20 minutes or so away, so I figured I had plenty of time. I threw my volunteer outfit in my backpack to get changed in the Volunteer office. All was going well until I was about to turn into the hospital campus, when I realized I was wearing my flip-flops, and didn't have any shoes. What was I to do? So I start going as fast as I can towards my house, obeying all speed limits, of course, but every single thing that goes wrong can. The exit for my house off the freeway is blocked. One street from my house, there is a large forklift in the middle of the road, suspending a large amount of wood in the air. There doesn't seem to be much movement, the forklift operator seems to be staring off into nowhere. Of course, I encounter this on the way back to the hospital as well. Overall, I was maybe 30 minutes late, gave a fake excuse of traffic and an accident on the freeway, and all was well. I tell them of this story now, and they love it – but it was way too nerve-wracking for my first day.

So, back to the real reason for this post: This summer. Having shadowed physicians for 2 summers now, I'd like to try and practice my skills (see my previous post). The first thing I did was write a letter to a family friend, who is a Family Practice doctor in a private office:

"Dear Dr. B,

My name is AMiB; I believe you know my parents D & D of [our Pharmacy]. I have recently completed my second preclinical year at the Bute Medical School, University of St. Andrews, UK, and am looking to spend my summer developing clinical aptitude in preparation for my clinical years to come. As part of our curriculum at the Bute, I have completed my theoretical studies of the Cardiovascular, Respiratory, Gastrointestinal, Renal, and Reproductive Systems; studying, in turn, the Anatomical, Physiological, Pathological, and Pharmacological aspects of each. As well as these, we have learned basic clinical and communication skills (see attached sheet of Scope of Practice). I feel that I must disclose, however, that both the Central Nervous and Endocrine Systems will be covered next year (our final preclinical year), and as such my knowledge of these fields is lacking.

My ideal situation for this summer would be that of a medical student, seeing patients, presenting to an attending Physician (preferably you or one of your partners, if willing), and learning about necessary treatments. I believe that learning by doing is a method that has been tried and tested in the medical education tradition for years, and I would like to continue that this summer. The knowledge I would gain, and the communication skills I would develop would be an invaluable addition to my medical education, and I would be deeply grateful.

If you are unable to have me for too long or feel that I am asking too much, I would still be honored if you would let me shadow you for a few days to get a feel for what Family Practice is like. Also, if you know of any clinics in the area that accept medical students in this role, or know of any other physicians, in any specialty, which might be willing to have me around, please put them in contact with me.

Attached, you will find my Scope of Practice, letter of indemnity coverage from the MDU (Medical Defense Union), and a letter from the Dean of my medical school approving my work for this summer."

I haven't yet received a response, but am hopeful. I also wrote a letter to an Internal Medicine doc that I met in the ER last summer. He is from India, and I'm hoping I might be able to pull the "we Indians got to stick together" card. But we'll see.

So yesterday I went to the hospital to see what I could do. Dr. C's office was all out to lunch, so I went and said hi to the Volunteer office. They offered me a Volunteer position, but there are a few people ahead of me to get set up with doc's, and I'd rather give that opportunity to a high schooler looking for something to put on their college app – after all, that's what I did. I went to the ER, and it turns out Dr. M is on vacation for all of June. I went to the Medical Staff office, and all but pleaded with them to give me privileges. Nothing. All I can do is Observe. They mentioned something about California State law and not being able to practice medicine without a license. They made it sound like I was trying to open up my own hospital – all I want to do is a simple H&P! Maybe start an IV or two, CVS exam…anything? Jeez…

Today I went back, said hi to Dr. C's office. This is why I think he is Dr. Amazing – he is going to ask around with some of his colleagues, Internists, Family Practice, and see if anyone is willing to take me on for the summer. He said he'll get in contact with me, so I'm anticipating an email from his office manager. While I'm not too hopeful, I'm really wishing something will come of it.

So I left my hospital, and went to another hospital down the street – they're all owned by the same overall organization/corporation (non-profit), but this was a different hospital campus altogether, and hopefully I might be able to find something here. Nope. Their office gave me the same deal – actually, their "no way" was much more enthusiastic than I got at my hospital. They told me that the law prohibits any patient contact from someone who is not licensed to practice medicine in the State of California. However they do have clerkships for final year students, but it is very difficult for International students to get approved for this.

I left very frustrated with the whole system. Honestly, why is it such a big deal? I'll sign your HIPAA forms, I won't give out medical advice, but let me do something! Sometimes, part of me wishes that I stuck with it and went through the American medical education system. I guess all I have to do is wait one more year until my clinical years start, but I tend to be a bit impatient sometimes.

If anyone out there has any advice, any connections, or any loopholes they know about, please, share them with me, either in the comments, or at veerthetiguy –AT- sbcglobal –DOT- net.

I'll be sure to keep everyone updated about the situation, but it looks like it'll be Observation only once again…

Until later,

-AMiB

Urigrow

http://www.youtube.com/watch?v=U-hMU8dwbtI

"After taking Urigrow(R) for just one week, I could see results like a thicker stream, less spray, more froth, and louder, deeper sounding urination."
From a recent episode of Saturday Night Live, if anyone was wondering.

Enjoy :-D