I'm chatting to a lovely man as I pull the bandage from the back of his head. He is charming the nurses, calling me "bellissima" and thanking us all for his care. The bandage is heavy and thick with blood. When I peel it away, I notice a pulse, a spurt of red from his lower scalp. I slam the gauze back in place and ask the nurse to apply pressure, then run to get the stapler.
12 staples, 5 sutures, 3 deep silk ties and a second doctor later, the bleeding has been contained down to a slow ooze. I'd asked the nurses to grab a second doc after I put the fifth suture in and the wound continued to spurt blood AROUND the closed tissue. I estimate that this poor man lost about a litre of blood between his fall (a simple trip) and getting his scalp closed.
As I wrote my notes, the sweat dried on my body and I thought, "Phew. First night back, pretty exciting..."
And then the PA called me to come see another patient.
PA's (physicians assistants) are a new thing in Canada. They have a 2 year diploma from a college and are employed to do the minor scut work in ER - placing simple sutures, casting, examining sore throats and ear infections, diagnosing UTI's. Some PA's are highly experienced, having worked in military medicine or been medical professionals outside of Canada.
Some are...not. This particular PA is about 19, has exactly 2 years of post-secondary education, and believes that she knows more than anyone in the department.
She grabbed me and said, "I think this patient is sick". I thought, "Uh oh". I walked into the room to see a person curled in the fetal position, shaking and pale. Temperature? 39 degrees. Heart rate? 110. Her voice was noticably muffled, as though her mouth was full of cotton wool. Or, say, a hot potato. Alarm bells began ringing all over my brain, and then the PA said, "I couldn't get a good look at the back of her throat, but I really tried!"
Kids, what is the most concerning diagnosis in this case?
If you said epiglottitis, you'd be right!
And kids, what is the NUMBER ONE rule of epiglottitis? A rule so fundamental that every medical student can recite it in their sleep? A rule so important that it is a pass/fail question on medical exams?
DO NOT EXAMINE THE THROAT OF A PATIENT WITH SUSPECTED EPIGLOTTITIS.
You are supposed to get the ENT team, the anaesthetists and a surgical OR ready before you even ask the patient to open their mouth wide. This is because an epiglottis can swell so quickly and completely obstruct the airway that even asking a patient to say, "Ahh" can be fatal.
Anyway, the PA got huffy when (after calling in ENT, pediatrics, anaesthetics and the OR team and seeing the patient safely shipped off) I suggested that next time she should not examine a patient's throat. "Well, I didn't think it was epiglottitis, so I needed to look!" she said.
First day back. I am ready for another vacation.
Tuesday, December 22, 2015
Tuesday, November 10, 2015
grades???
I miss residency.
Alas, I am not joking. I don't miss the mandatory shift hours, the scut work or having to run every decision by someone subjectively senior to you.
What I miss is the feedback.
After every shift, I want someone to go through my list of patients and say, "You know, you could have done this better, but overall, you did a good job tonight"...
I realised this at the end of my second solo night shift. (Yep, just me, in charge of the whole ER, through a long and hectic night).
As I was leaving, a nurse grabbed me.
"Doctor, you've written a prescription for the kid in room 3?"
"Yes!" I cheerily replied.
"Yeah, you've written it on the chart for room 6..."
I groaned, tore up the script and made a joke about how I wouldn't be safe to drive home, as my brain was all goopy. The nurse smiled politely, but then, as I was leaving said, "You're doing a good job".
I stopped, frozen in place. "Sorry?"
"You're doing a good job! Have a good sleep."
The words were like pure chocolate, a rush of warmth and sugar and support and validation and...
And that's when I realised. I miss residency. I need external validation, which grownups don't get. So yes, maybe I'll go back to school. That critical care fellowship looks appealing. Just another 5 years of school???
Alas, I am not joking. I don't miss the mandatory shift hours, the scut work or having to run every decision by someone subjectively senior to you.
What I miss is the feedback.
After every shift, I want someone to go through my list of patients and say, "You know, you could have done this better, but overall, you did a good job tonight"...
I realised this at the end of my second solo night shift. (Yep, just me, in charge of the whole ER, through a long and hectic night).
As I was leaving, a nurse grabbed me.
"Doctor, you've written a prescription for the kid in room 3?"
"Yes!" I cheerily replied.
"Yeah, you've written it on the chart for room 6..."
I groaned, tore up the script and made a joke about how I wouldn't be safe to drive home, as my brain was all goopy. The nurse smiled politely, but then, as I was leaving said, "You're doing a good job".
I stopped, frozen in place. "Sorry?"
"You're doing a good job! Have a good sleep."
The words were like pure chocolate, a rush of warmth and sugar and support and validation and...
And that's when I realised. I miss residency. I need external validation, which grownups don't get. So yes, maybe I'll go back to school. That critical care fellowship looks appealing. Just another 5 years of school???
Tuesday, November 3, 2015
Unleash the Sharpei!
Sometimes, a man's foreskin gets stuck in the retracted position. The tight band of the inflexible foreskin acts as a barrier to return blood flow, causing the head of the penis to swell, become engorged, turn red, turn black and eventually (if left long enough) fall off.
This happens most commonly in little boys - kids who play with their foreskin and forget to replace it. It can sometimes happen in men with botched circumcisions, who have lots of scar tissue on their remaining foreskin. And sometimes, little old men with dementia wake up for a pee during the night and forget to put the turtle back in its shell before going back to bed. This was my patient.
The great news is that my patient, a gentleman of some advanced years, did not have any pain with his paraphimosis. Yes, his penis was red, swollen and tender to touch, but he was pleasantly unaffected by the pain. His adult daughter was beside herself, wanting to support her father during his ER visit, but also really really really not wanting to see her Dad's schlong. We did a dance, trading places every time I went in and out of the room.
The treatments for paraphimosis are varied and mostly case studies. It doesn't happen often enough for a large body of evidence to exist. Sometimes people drain the blood with needles. Sometimes people use force to drag the foreskin over the mushroom cap. And sometimes you simply slice through that foreskin with a scalpel, releasing the tension and sending a wave of stagnant blood back into the body.
I did not do this. I dipped a stretchy bandage into a 50% sugar solution. I wrapped the wet bandage around the swollen red tissue firmly, but not tightly. I walked away (do-si-do with the daughter) and came back in 5 minutes. Then, I gently but firmly eased the foreskin over the now-shrunken penis. The osmotic pressure from the dextrose solution pulls the fluid from the foreskin. The compression helps. It all moisturizes the tissue and boom! The pig is back in his blanket.
I was lucky. I don't know if I could slice a confused old man's penis with a blade. But medicine with a spoonful of sugar? Happy to provide.
This happens most commonly in little boys - kids who play with their foreskin and forget to replace it. It can sometimes happen in men with botched circumcisions, who have lots of scar tissue on their remaining foreskin. And sometimes, little old men with dementia wake up for a pee during the night and forget to put the turtle back in its shell before going back to bed. This was my patient.
The great news is that my patient, a gentleman of some advanced years, did not have any pain with his paraphimosis. Yes, his penis was red, swollen and tender to touch, but he was pleasantly unaffected by the pain. His adult daughter was beside herself, wanting to support her father during his ER visit, but also really really really not wanting to see her Dad's schlong. We did a dance, trading places every time I went in and out of the room.
The treatments for paraphimosis are varied and mostly case studies. It doesn't happen often enough for a large body of evidence to exist. Sometimes people drain the blood with needles. Sometimes people use force to drag the foreskin over the mushroom cap. And sometimes you simply slice through that foreskin with a scalpel, releasing the tension and sending a wave of stagnant blood back into the body.
I did not do this. I dipped a stretchy bandage into a 50% sugar solution. I wrapped the wet bandage around the swollen red tissue firmly, but not tightly. I walked away (do-si-do with the daughter) and came back in 5 minutes. Then, I gently but firmly eased the foreskin over the now-shrunken penis. The osmotic pressure from the dextrose solution pulls the fluid from the foreskin. The compression helps. It all moisturizes the tissue and boom! The pig is back in his blanket.
I was lucky. I don't know if I could slice a confused old man's penis with a blade. But medicine with a spoonful of sugar? Happy to provide.
Thursday, October 8, 2015
Suddenly, everything is terrible...
I've started my new job. ER in a busy city hospital. The patients are less wealthy, less healthy and need more done for them.
The staff (my colleagues) are stereotypical ER docs - big egos, borderline offensive jokes, lots of back-slapping and ribbing on the scene.
Sample: "This is John. He's the less virile Smith brother - he only has 3 kids!"
John: "Says the guy who can't get it up at all!"
etc etc...
These guys are all about the numbers. Their sense of professional satisfaction is tied to how much meat they can move and they are not interested in being slowed down by a new doc who hasn't figured out the computer system or how to cherry-pick the rapid cases.
On my first shift, I got left with 5 (FIVE!) sick, elderly, demented patients who had been transferred from nursing homes. All of these patients needed admitting for various reasons. By the time I presented the third admission to the medicine doc, she was irate. She took my arm and marched me down to a more senior ER guy.
"Your colleagues have screwed over this girl", she said. He looked vaguely annoyed and made excuses about the new pickup system.
"No!", she said. "She is getting screwed over because she doesn't know enough and your colleagues took advantage of her!"
While I do appreciate the support, this is not a good way to get introduced to your team. This guy took me aside later and suggested that I bring in some home baking "to help get people on your side".
In addition to this humiliation, I also got blindsided by a PA. A physician's assistant. These are people who have a 2 year undergrad degree and are supposed to see low acuity patients. This PA had taken on a complex patient and (hindsight being 20/20) totally ignored her diagnosis, while focusing on her chest pain. She was in ER for 12 hours with no pain relief and turned out to have a broken hip.
My 8 hour shift lasted 11 hours. The admitting medicine doc (correctly) thinks I'm an idiot. My new ER team think I'm a pushover. I am not meeting my targets for patients to be seen. I am not providing very good care. And I have committed to 5 years at this hospital.
Maybe I'll run away and live in the country. When I work at Smalltown Hospital, I have great patient interactions, I have great relationships with the admitting docs, the nurses and I get along and (most importantly) my numbers are GREAT!
One week down, 259 to go.
The staff (my colleagues) are stereotypical ER docs - big egos, borderline offensive jokes, lots of back-slapping and ribbing on the scene.
Sample: "This is John. He's the less virile Smith brother - he only has 3 kids!"
John: "Says the guy who can't get it up at all!"
etc etc...
These guys are all about the numbers. Their sense of professional satisfaction is tied to how much meat they can move and they are not interested in being slowed down by a new doc who hasn't figured out the computer system or how to cherry-pick the rapid cases.
On my first shift, I got left with 5 (FIVE!) sick, elderly, demented patients who had been transferred from nursing homes. All of these patients needed admitting for various reasons. By the time I presented the third admission to the medicine doc, she was irate. She took my arm and marched me down to a more senior ER guy.
"Your colleagues have screwed over this girl", she said. He looked vaguely annoyed and made excuses about the new pickup system.
"No!", she said. "She is getting screwed over because she doesn't know enough and your colleagues took advantage of her!"
While I do appreciate the support, this is not a good way to get introduced to your team. This guy took me aside later and suggested that I bring in some home baking "to help get people on your side".
In addition to this humiliation, I also got blindsided by a PA. A physician's assistant. These are people who have a 2 year undergrad degree and are supposed to see low acuity patients. This PA had taken on a complex patient and (hindsight being 20/20) totally ignored her diagnosis, while focusing on her chest pain. She was in ER for 12 hours with no pain relief and turned out to have a broken hip.
My 8 hour shift lasted 11 hours. The admitting medicine doc (correctly) thinks I'm an idiot. My new ER team think I'm a pushover. I am not meeting my targets for patients to be seen. I am not providing very good care. And I have committed to 5 years at this hospital.
Maybe I'll run away and live in the country. When I work at Smalltown Hospital, I have great patient interactions, I have great relationships with the admitting docs, the nurses and I get along and (most importantly) my numbers are GREAT!
One week down, 259 to go.
Tuesday, September 8, 2015
cordial
During my ICU rotation, we had a very sick patient. The traditional cocktail of medications and machines were doing nothing and we, as residents, were stumped. We appealed to the Big Boss - what were we missing? What secret twist or turn would bring this patient back?
He shrugged. "I guess we could try methylene blue?"
And so we hooked a bag of blue dye to the patient's vein. It looked like a melted popsicle was running through the IV. Over some days, the patient did get better.
My boss couldn't explain why or how it had worked, just that he sometimes tried it, "When I'm out of ideas".
This case keeps coming to mind as I run through cases and old exam questions. Yes, on paper, the patient has A, we give B and the outcome is C. It's formulaic and relies on pattern recognition and memorisation.
In the ER where I work, I have yet to see a formulaic patient. The 7 year old girl with seizures? Could have been heat stroke, could have been meningitis. The 70 year old with a stroke? Also had renal failure and a cardiac event. The guy who shot himself with a nail gun? Well, actually, he was pretty easy to manage (pliers and a strong counterforce).
It reassures me, as I shuffle piles of paper and sort through antibiotic classes. Even my senior bosses sometimes have no idea. My patients haven't read the textbook. My nurses "smell" the diagnosis before I've walked in the room. The cops tell me someone is "hot and crazy" and know what to do.
Now I just have to convince a panel of examiners that all this is true.
When in doubt, give methylene blue.
He shrugged. "I guess we could try methylene blue?"
And so we hooked a bag of blue dye to the patient's vein. It looked like a melted popsicle was running through the IV. Over some days, the patient did get better.
My boss couldn't explain why or how it had worked, just that he sometimes tried it, "When I'm out of ideas".
This case keeps coming to mind as I run through cases and old exam questions. Yes, on paper, the patient has A, we give B and the outcome is C. It's formulaic and relies on pattern recognition and memorisation.
In the ER where I work, I have yet to see a formulaic patient. The 7 year old girl with seizures? Could have been heat stroke, could have been meningitis. The 70 year old with a stroke? Also had renal failure and a cardiac event. The guy who shot himself with a nail gun? Well, actually, he was pretty easy to manage (pliers and a strong counterforce).
It reassures me, as I shuffle piles of paper and sort through antibiotic classes. Even my senior bosses sometimes have no idea. My patients haven't read the textbook. My nurses "smell" the diagnosis before I've walked in the room. The cops tell me someone is "hot and crazy" and know what to do.
Now I just have to convince a panel of examiners that all this is true.
When in doubt, give methylene blue.
Sunday, August 16, 2015
newbie
What did you see during your first week of work?
I saw a kid who had been out in the sun all day. Her core temperature was 40 degrees celsius and her brain was cooked like an egg. We cooled her down until the helicopter could come to transfer her to the children's hospital.
I saw a glass dildo sitting high in someone's tummy; I wanted to ask them, "If you're going to spend all that money to put things in your butt, shouldn't you make sure they're butt friendly?" I want to make pamphlets for the waiting room: All about that bass? Try a flared base!
I saw a toe that had been disconnected from it's owner (mostly) and reunited these lost friends.
I saw a nail through a thumb that somehow missed the bone. The owner was learning to be a roofer. It was his first hour on the job. I suggested alternative career options as we yanked it out.
I saw fractures and cuts and coughs and colds and sore tummies and hernias and one thousand vaginas and one swollen ball.
All in all, a good week, I think.
I saw a kid who had been out in the sun all day. Her core temperature was 40 degrees celsius and her brain was cooked like an egg. We cooled her down until the helicopter could come to transfer her to the children's hospital.
I saw a glass dildo sitting high in someone's tummy; I wanted to ask them, "If you're going to spend all that money to put things in your butt, shouldn't you make sure they're butt friendly?" I want to make pamphlets for the waiting room: All about that bass? Try a flared base!
I saw a toe that had been disconnected from it's owner (mostly) and reunited these lost friends.
I saw a nail through a thumb that somehow missed the bone. The owner was learning to be a roofer. It was his first hour on the job. I suggested alternative career options as we yanked it out.
I saw fractures and cuts and coughs and colds and sore tummies and hernias and one thousand vaginas and one swollen ball.
All in all, a good week, I think.
Tuesday, August 4, 2015
Heavy Metal
The median level of ferritin in women is 45. This means that roughly half of women (surveyed in an American study) are low in iron. The study also found that women who were iron-deficient perform worse on basic cognitive tests.
Extrapolating from this, half of women are not meeting their cognitive potential due to low iron levels.
This information was delivered to me by my emergency medicine podcast, as I drove home from my first staff shift. My immediate thought was, "Well obviously! The patriarchy keeps us malnourished to prevent us from reaching our potential!"
Hear me out...
Society pushes women to be thin and sweet and docile. This involves being gentle - not red meat eating carnivores, but salad grazing ladies. This means eating less; smaller portions proportional to our dietary needs. This means eating restrictive diets that prevent women from getting their required levels of iron, folate and thiamine; all required to maintain healthy hemoglobin levels.
I'm not saying the patriarchy is consciously forcing women to have a low-iron diet in the hopes of keeping them docile and dumb. I'm just saying it's a nice coincidence that the same societal mandates that keep us hungry and weak also work to keep us cognitively slow and cardiovascularly deplete.
I got a nice rage burn as I drove. I pulled a chicken bone out of someone's tonsil yesterday, no sedation required, so I'm pretty sure I'm at the top of my game. And my iron levels are spectacular. Fight the patriarchy! Eat a steak! Or take your ferrous gluconate regularly.
Extrapolating from this, half of women are not meeting their cognitive potential due to low iron levels.
This information was delivered to me by my emergency medicine podcast, as I drove home from my first staff shift. My immediate thought was, "Well obviously! The patriarchy keeps us malnourished to prevent us from reaching our potential!"
Hear me out...
Society pushes women to be thin and sweet and docile. This involves being gentle - not red meat eating carnivores, but salad grazing ladies. This means eating less; smaller portions proportional to our dietary needs. This means eating restrictive diets that prevent women from getting their required levels of iron, folate and thiamine; all required to maintain healthy hemoglobin levels.
I'm not saying the patriarchy is consciously forcing women to have a low-iron diet in the hopes of keeping them docile and dumb. I'm just saying it's a nice coincidence that the same societal mandates that keep us hungry and weak also work to keep us cognitively slow and cardiovascularly deplete.
I got a nice rage burn as I drove. I pulled a chicken bone out of someone's tonsil yesterday, no sedation required, so I'm pretty sure I'm at the top of my game. And my iron levels are spectacular. Fight the patriarchy! Eat a steak! Or take your ferrous gluconate regularly.
Thursday, July 30, 2015
pants off dance off
Three things are happening.
1. I am studying for (yet another) exam. My pants are off, my hand is stained with chocolate chips, my eyes are sore and my mind is wandering.
2. I've been listening to the podcast, "Adults read things they wrote as kids". It is exactly what it sounds like, and the results are often hilarious and sometimes poignant reminders of what it was like to be writing stories and diaries and journals and (eep!) poems as a boy-crazy kid and angsty adolescent.
3. We're finishing unpacking our house, sorting through all our books and papers as we put them out on shelves. I found my old blog archive and have been reading through it.
These events are coming together to form a perfect storm.
I am having flashbacks to every exam I've studied for previously. Long days in the UBC library, curled over molecular biology texts. Sending mass email quizzes to all my friends so they would write back and divert my attention during study breaks (the world before facebook). Chugging diet pepsi and sitting at my little blue desk in my little blue bedroom at my parents house, playing CDs (CDs!) to mark the time I could start and stop working. Perspiring it out in Australia, experiencing my first page-curling palm sweat that rippled my notes. Googling boys and pictures of cute puppies and babies. Writing diary entries and blog posts and study haikus and...
Anyways. This is my last exam. Ever. I'm getting better at studying. More efficient. Enjoying my breaks more (baby cuddles are way better than pictures) and feeling less guilty about eating all the junk.
I do have a worrying urge to send out a mass email to all my 2001 friends. Answer the following questions and i'll send you my answers. I actually saved all their answers from back in the day, but alas, they're on discs. I'll keep thinking about what i want to know...
What book are you reading right now?
What song is MAKING your summer?
Who are you thinking about kissing? (Way more interesting before everyone got married...)
What's the weirdest thing you've ever done in the library?
What should I google right now?
All this, plus comforting manatees.
One last exam. ONE MORE TO GO.
1. I am studying for (yet another) exam. My pants are off, my hand is stained with chocolate chips, my eyes are sore and my mind is wandering.
2. I've been listening to the podcast, "Adults read things they wrote as kids". It is exactly what it sounds like, and the results are often hilarious and sometimes poignant reminders of what it was like to be writing stories and diaries and journals and (eep!) poems as a boy-crazy kid and angsty adolescent.
3. We're finishing unpacking our house, sorting through all our books and papers as we put them out on shelves. I found my old blog archive and have been reading through it.
These events are coming together to form a perfect storm.
I am having flashbacks to every exam I've studied for previously. Long days in the UBC library, curled over molecular biology texts. Sending mass email quizzes to all my friends so they would write back and divert my attention during study breaks (the world before facebook). Chugging diet pepsi and sitting at my little blue desk in my little blue bedroom at my parents house, playing CDs (CDs!) to mark the time I could start and stop working. Perspiring it out in Australia, experiencing my first page-curling palm sweat that rippled my notes. Googling boys and pictures of cute puppies and babies. Writing diary entries and blog posts and study haikus and...
Anyways. This is my last exam. Ever. I'm getting better at studying. More efficient. Enjoying my breaks more (baby cuddles are way better than pictures) and feeling less guilty about eating all the junk.
I do have a worrying urge to send out a mass email to all my 2001 friends. Answer the following questions and i'll send you my answers. I actually saved all their answers from back in the day, but alas, they're on discs. I'll keep thinking about what i want to know...
What book are you reading right now?
What song is MAKING your summer?
Who are you thinking about kissing? (Way more interesting before everyone got married...)
What's the weirdest thing you've ever done in the library?
What should I google right now?
All this, plus comforting manatees.
One last exam. ONE MORE TO GO.
Wednesday, July 15, 2015
googles, "how much is botox"...
When the patient's mother grabs me and says, "Are you the staff?" I am momentarily chuffed.
I must look authoritative. Mature. Confident in my medical professionalism.
"I'm not", I say. "But what can I help you with?"
"We want another doctor. Our doctor looks too young."
Sigh.
I am in that delightful stage where I look haggard enough to be staff, but am inexperienced enough to need someone supervising me.
The fun part about working at the Children's Hospital is that I am not supposed to know how to manage kids, so people give me lots of help and training and double check my plans.
(They also ask me for help with ER specific problems; last night I used ultrasound to place a hematoma block and reduce a Bennet's fracture, which is a bit of a rock star move. FYI.)
The less fun part is that the junior residents look about 12 years old and I keep mixing them up with the patients.
Oh well. Wiggly butts, rashes, minions teeshirts and therapeutic popsicles. Pediatric ER is not all bad.
Tuesday, July 7, 2015
Routine
Elective time.
Drive a million miles, arrive at a musty-smelling home with sad motel furniture.
Claim a room, figure out which couch is comfiest.
How many channels do you get?
The wifi password is Isengard? How are you nerdy enough to have that password, but misspell Isengaard? How did I notice?
I think the hospital is walking distance to here, but where is the nearest LCBO?
Yelp "best delivery thai Ottawa".
Is this pad thai? The soup tastes like dirty bathwater.
Man, I wish this place had air conditioning, but at least it's clean.
Why can't I log into my schedule?
I think my first shift is tomorrow. Where are my scrubs? Did I forget to pack my scrubs?
I have done this every year, several times a year, for about 10 years. This is my last elective. Unusually, I have my family with me to help settle in, and also make things complicated (I know which couch is comfiest and I'm not currently on it.) Three weeks, then I'm done. Living in one place for more than a year at a time. Making a paycheque. Deciding what shifts I want to work and when...
Now all I need is a recommendation for good delivery food in Ottawa.
Drive a million miles, arrive at a musty-smelling home with sad motel furniture.
Claim a room, figure out which couch is comfiest.
How many channels do you get?
The wifi password is Isengard? How are you nerdy enough to have that password, but misspell Isengaard? How did I notice?
I think the hospital is walking distance to here, but where is the nearest LCBO?
Yelp "best delivery thai Ottawa".
Is this pad thai? The soup tastes like dirty bathwater.
Man, I wish this place had air conditioning, but at least it's clean.
Why can't I log into my schedule?
I think my first shift is tomorrow. Where are my scrubs? Did I forget to pack my scrubs?
I have done this every year, several times a year, for about 10 years. This is my last elective. Unusually, I have my family with me to help settle in, and also make things complicated (I know which couch is comfiest and I'm not currently on it.) Three weeks, then I'm done. Living in one place for more than a year at a time. Making a paycheque. Deciding what shifts I want to work and when...
Now all I need is a recommendation for good delivery food in Ottawa.
Wednesday, June 10, 2015
Killing it!
What happens if you take all the drugs, then all the pills, then decide to take a little sleep? ICU!
What happens when your stomach starts bleeding and we suction 2L of frank red blood out of your esophagus and end up needing a transfusion of 15 units? ICU.
What if your balls turn black and the skin starts flaking off them and you get a fever? ICU.
Emergency C-section for placental abruption due to cocaine use? ICU.
Morbid obesity preventing you from breathing? ICU.
Anorexia stopping your heart from beating? ICU.
Fall down go boom brain bleed? ICU.
It's been a good rotation so far. I'm tubing and lining and tapping everyone. The nurses have finally learned my name and let me sleep at least one hour per call shift (5-6am, holla!). I have supervised my juniors and taught them things and haven't bitch-slapped the one who suggested I'm dumb cos I have a baby (win!). They've offered me a job covering the weekends that will give me ludicrous amounts of money and lots of chances to learn.
Am I winning at ICU? I'm winning at ICU.
I want to call in sick for the next two weeks, stay home and play with my baby, but I'm winning to ICU.
What happens when your stomach starts bleeding and we suction 2L of frank red blood out of your esophagus and end up needing a transfusion of 15 units? ICU.
What if your balls turn black and the skin starts flaking off them and you get a fever? ICU.
Emergency C-section for placental abruption due to cocaine use? ICU.
Morbid obesity preventing you from breathing? ICU.
Anorexia stopping your heart from beating? ICU.
Fall down go boom brain bleed? ICU.
It's been a good rotation so far. I'm tubing and lining and tapping everyone. The nurses have finally learned my name and let me sleep at least one hour per call shift (5-6am, holla!). I have supervised my juniors and taught them things and haven't bitch-slapped the one who suggested I'm dumb cos I have a baby (win!). They've offered me a job covering the weekends that will give me ludicrous amounts of money and lots of chances to learn.
Am I winning at ICU? I'm winning at ICU.
I want to call in sick for the next two weeks, stay home and play with my baby, but I'm winning to ICU.
Saturday, May 30, 2015
24 hours
At three thirty on Tuesday afternoon, I sat in the library basement with my baby on my lap. We sang songs and passed toys around a circle of babies and carers. We clapped our hands, we stomped our feet, we shouted hurray! (We were happy and we knew it).
At three thirty Tuesday morning, I was doing chest compressions.
A young guy who worked at the hospital was chatting to his girlfriend on the phone. She said they were laughing and then suddenly he stopped.
She heard, "Oh my god, babe..." and then a horrible moaning sound. The phone dropped. The girlfriend also works at the hospital and called security to go find him. He was in an upper hallway, and by the time security got to him, he had been down for about 15 minutes. They called the code blue. We arrived and started doing all the things we do. Chest compressions. Intubation. Drilling into his bones so we could give IV fluids, drugs and electrolytes.
His girlfriend arrived and watched the whole process, sobbing and repeating, "He's ok. He's ok. He's fine..."
Blood started coming up the tube. We suctioned about a litre in the first 5 minutes. He still didn't have a pulse. More epinephrine. More bicarb. More compressions. Ten minutes passed. Twenty. Still no pulse. No shockable rhythms.
Finally, the code doc called it. After 30 minutes of no return of circulation, there's not going to be a heartbeat. We stopped working on him and started to pack up. Because it was a mysterious death, we weren't allowed to remove his tubes or wires. The coroner was called to assess the scene. The police were involved. The girlfriend lay across her partner's body and gently stroked his hair.
"We had such a nice conversation..." she said.
It was a bad night.
12 hours later, I held a chubby squirmy girl in my lap and nuzzled into the softness of her neck. I sang songs to her and tried not to think about having to do compressions on her. Or having to drill into her bones. Or having to put a tube in her throat.
99% of the time, my job is awesome. The other 1% gives me nightmares.
At three thirty Tuesday morning, I was doing chest compressions.
A young guy who worked at the hospital was chatting to his girlfriend on the phone. She said they were laughing and then suddenly he stopped.
She heard, "Oh my god, babe..." and then a horrible moaning sound. The phone dropped. The girlfriend also works at the hospital and called security to go find him. He was in an upper hallway, and by the time security got to him, he had been down for about 15 minutes. They called the code blue. We arrived and started doing all the things we do. Chest compressions. Intubation. Drilling into his bones so we could give IV fluids, drugs and electrolytes.
His girlfriend arrived and watched the whole process, sobbing and repeating, "He's ok. He's ok. He's fine..."
Blood started coming up the tube. We suctioned about a litre in the first 5 minutes. He still didn't have a pulse. More epinephrine. More bicarb. More compressions. Ten minutes passed. Twenty. Still no pulse. No shockable rhythms.
Finally, the code doc called it. After 30 minutes of no return of circulation, there's not going to be a heartbeat. We stopped working on him and started to pack up. Because it was a mysterious death, we weren't allowed to remove his tubes or wires. The coroner was called to assess the scene. The police were involved. The girlfriend lay across her partner's body and gently stroked his hair.
"We had such a nice conversation..." she said.
It was a bad night.
12 hours later, I held a chubby squirmy girl in my lap and nuzzled into the softness of her neck. I sang songs to her and tried not to think about having to do compressions on her. Or having to drill into her bones. Or having to put a tube in her throat.
99% of the time, my job is awesome. The other 1% gives me nightmares.
Monday, April 20, 2015
rich mouse, poor mouse
What's the difference between ER in O-town and ER in Big Smoke?
The approach to the drug seeking patient.
O-town is a wealthy area of the province. Most of the patients are well dressed, ask for the wifi password while they wait (so they can play on their i-pads) and have access to insurance that covers extended benefits.
It was a delight - I was treating back pain with physiotherapy referrals (best option!), giving the appropriate medication for the condition (even if not on ODB!) and talking to patients who really, truly believed that their health was a priority.
Contrast this to my previous work at Big Smoke ER, in the inner city. There, patients would be wearing soiled, thin clothing, ask if they could have a sandwich while they waited and let me know that while their health is important to them, they were not able to give it their full attention at this time.
The number one difference became apparent when I met a man who was asking for a refill of his oxyneo prescription. He told me he had dropped his pills in the sink and so he needed enough to get him through the weekend. He told me he was taking 80mg four times a day. He told me he had been taking this amount for years.
If this patient had walked into Big Smoke ER, we would have laughed him out the door. Patients with addictions are offered help to quit and directed to supportive chronic care, but they are NOT given massive doses of opiates cos they dropped theirs "down the sink". Honestly, the addicts downtown will know this and at least give a more creative story. They fake a serious injury. They say they've never had this pain before. And they don't ask for a dose that would level a hippopotamus.
I carefully documented this conversation and went to chat to my boss. "I'm going to offer him the number of addictions services, a family physician number and tell him not to come back to ER", I said.
The boss said, "Enh. We get these guys so rarely. Just give him a few days worth and send him home."
I prescribed enough oxyneo to kill several people and sent this (surprised but excited) young man out the door. This does not sit well with me.
I think I am not well suited to the easy, cut and dried, clean and wealthy medicine of O-town. I think I am supposed to be surrounded by chaos and serious pathology and patients with bed bugs. I think I am meant to have my new job. I'm excited, and ready, to say no to drugs.
The approach to the drug seeking patient.
O-town is a wealthy area of the province. Most of the patients are well dressed, ask for the wifi password while they wait (so they can play on their i-pads) and have access to insurance that covers extended benefits.
It was a delight - I was treating back pain with physiotherapy referrals (best option!), giving the appropriate medication for the condition (even if not on ODB!) and talking to patients who really, truly believed that their health was a priority.
Contrast this to my previous work at Big Smoke ER, in the inner city. There, patients would be wearing soiled, thin clothing, ask if they could have a sandwich while they waited and let me know that while their health is important to them, they were not able to give it their full attention at this time.
The number one difference became apparent when I met a man who was asking for a refill of his oxyneo prescription. He told me he had dropped his pills in the sink and so he needed enough to get him through the weekend. He told me he was taking 80mg four times a day. He told me he had been taking this amount for years.
If this patient had walked into Big Smoke ER, we would have laughed him out the door. Patients with addictions are offered help to quit and directed to supportive chronic care, but they are NOT given massive doses of opiates cos they dropped theirs "down the sink". Honestly, the addicts downtown will know this and at least give a more creative story. They fake a serious injury. They say they've never had this pain before. And they don't ask for a dose that would level a hippopotamus.
I carefully documented this conversation and went to chat to my boss. "I'm going to offer him the number of addictions services, a family physician number and tell him not to come back to ER", I said.
The boss said, "Enh. We get these guys so rarely. Just give him a few days worth and send him home."
I prescribed enough oxyneo to kill several people and sent this (surprised but excited) young man out the door. This does not sit well with me.
I think I am not well suited to the easy, cut and dried, clean and wealthy medicine of O-town. I think I am supposed to be surrounded by chaos and serious pathology and patients with bed bugs. I think I am meant to have my new job. I'm excited, and ready, to say no to drugs.
Wednesday, April 8, 2015
Back in the Saddle
Butt bleeds. Peritonism. Dialysis patients with infected lines. Dudes who can't pee.
A four year old who was afraid to be examined until I gave her a smile. She turned and whispered something to her Mum, who said, "She DOES look like Doc McStuffins!" and then she let me poke her in the eye.
Asking the back dude if he had had any erections since his injury. When he hesitated, I prompted, "Not even morning wood? Or...a more professional way of saying that?" He and his girlfriend laughed and then it was a little less awkward when I tickled his anus with a Q-tip.
I am so so so rusty. I didn't give pantoprazole to the guy with the upper GI bleed! (Mr G shrugged when I said this, but it's the equivalent of not giving morphine to someone with appendicitis...)
I forgot to give morphine to my lady with appendicitis.
The thing is, everyone was really nice, the nurses are great, my staff doc was SO fun to work with and I got to do some bone crunching in a little old lady wearing fabulous sunglasses.
I was very happy to go home and watch my baby sleep on the monitor. And it was nice to have today off. But
I still love my job. Yay!
A four year old who was afraid to be examined until I gave her a smile. She turned and whispered something to her Mum, who said, "She DOES look like Doc McStuffins!" and then she let me poke her in the eye.
Asking the back dude if he had had any erections since his injury. When he hesitated, I prompted, "Not even morning wood? Or...a more professional way of saying that?" He and his girlfriend laughed and then it was a little less awkward when I tickled his anus with a Q-tip.
I am so so so rusty. I didn't give pantoprazole to the guy with the upper GI bleed! (Mr G shrugged when I said this, but it's the equivalent of not giving morphine to someone with appendicitis...)
I forgot to give morphine to my lady with appendicitis.
The thing is, everyone was really nice, the nurses are great, my staff doc was SO fun to work with and I got to do some bone crunching in a little old lady wearing fabulous sunglasses.
I was very happy to go home and watch my baby sleep on the monitor. And it was nice to have today off. But
Monday, April 6, 2015
Game On!
Things I am allowed to think about between now and September:
1. My family (baby + Mr G)
2. My job (emergency med residency - last 4 months!)
3. My upcoming exam (EM. All of it.)
Things I am not allowed to think about before September:
1. My butt. Yes, it's a little flatter post-baby, but I am not allowed to think about lunging, working my glutes or power squats until this is all over.
2. My social life. I have wonderful, supportive friends who bring light and joy into my life. I cannot see them until I have learned ALL the medicine.
3. My family (extended version). Yes, I will call them and send photos and whinge to them about my current life situation, but I cannot let my need to see them distract me.
4. Summer. (Does not apply, this year)
5. Nutritional balance - if I eat ONLY microwaved weight watchers meals, this will give me more time to study.
6. The Kardashians. Or the Gallaghers. Or Mindy Lahiri. Or the Lannisters. I am off all delightful forms of media until this is all over.
Starting tomorrow I am back to work. My first shift is from 2-10pm at a regional hospital and I am both calm (it's my happy place!) and terrified (what's a heart attack?).
I am so glad I get to go back to being a resident, as this means someone will be looking over my shoulder and hopefully stopping me BEFORE I kill someone.
I am worried that I will not be able to stay awake through the whole shift. I am worried that I will lactate during the shift. I am worried that I won't remember what blood tests I need to order, or that I will miss my Bub so much that I can't function. But...
I am not allowed to think about these things, starting tomorrow. As of tomorrow, it's game on.
1. My family (baby + Mr G)
2. My job (emergency med residency - last 4 months!)
3. My upcoming exam (EM. All of it.)
Things I am not allowed to think about before September:
1. My butt. Yes, it's a little flatter post-baby, but I am not allowed to think about lunging, working my glutes or power squats until this is all over.
2. My social life. I have wonderful, supportive friends who bring light and joy into my life. I cannot see them until I have learned ALL the medicine.
3. My family (extended version). Yes, I will call them and send photos and whinge to them about my current life situation, but I cannot let my need to see them distract me.
4. Summer. (Does not apply, this year)
5. Nutritional balance - if I eat ONLY microwaved weight watchers meals, this will give me more time to study.
6. The Kardashians. Or the Gallaghers. Or Mindy Lahiri. Or the Lannisters. I am off all delightful forms of media until this is all over.
Starting tomorrow I am back to work. My first shift is from 2-10pm at a regional hospital and I am both calm (it's my happy place!) and terrified (what's a heart attack?).
I am so glad I get to go back to being a resident, as this means someone will be looking over my shoulder and hopefully stopping me BEFORE I kill someone.
I am worried that I will not be able to stay awake through the whole shift. I am worried that I will lactate during the shift. I am worried that I won't remember what blood tests I need to order, or that I will miss my Bub so much that I can't function. But...
I am not allowed to think about these things, starting tomorrow. As of tomorrow, it's game on.
Thursday, February 26, 2015
s'not that bad
Human orifices are lined with epithelial tissue. (In other words, there is wet stuff in your holes. )This "mucus membrane" acts as a barrier to infection. It has all kinds of defence mechanisms.
When you get sick, the mucus membrane kicks into action, producing "mucin", a polysaccharide complex that absorbs water. Snot, to y'all. This thick layer of snot prevents further viral particles from penetrating and sloughs existing particles away.
As a side note, polysaccharide is a fancy word for "complex sugar molecule", which is why snot tastes vaguely sweet. Ask any 3 year old.
Why discuss this rather intemperate subject?
Cos I have been vacuuming snot out of my lovely daughter's nostrils with a hose-pipe connected to my mouth.
We have walked on the moon, we hold the world's knowledge in a pocket-sized computer, but we still haven't figured out how to get boogers out of tiny nostrils. This is a problem.
Babies can only breathe through their nostrils (mouth-breathing is a sadly acquired trait) and when those nostrils are blocked, they stop eating and sleeping. You may not realise this, but eating and sleeping are the only things babies want to do, hence the snot-vacuum. It's a little bulb that inserts into her nose (she loves this about as much as you would) and connects to a flexible straw. The straw connects to my lips. To prevent liquid mucus from entering my mouth, a thin paper "filter" is poked between bulb and straw. It works about 40% of the time.
I shove the bulb in and start hyperventilating so I can generate as much suction as possible without passing out. A chunk materialises in the bulb, Bub's cries get clearer (and LOUDER) and then we calm her by poking a nipple in her mouth. Mine, for what it's worth.
The past few days, I've been repeating this procedure every 2 hours. Bub hates it, I hate it and Mr G gets queasy just watching. The glamour and reward of parenting.
Makes me nostalgic for work, where the suction is connected to the wall, and I rarely get bitten after making someone feel better.
PS: Yes, I'm spelling it mucus. Mucus is the substance. Mucous means "pertaining to, or related to mucus". Look it up.
When you get sick, the mucus membrane kicks into action, producing "mucin", a polysaccharide complex that absorbs water. Snot, to y'all. This thick layer of snot prevents further viral particles from penetrating and sloughs existing particles away.
As a side note, polysaccharide is a fancy word for "complex sugar molecule", which is why snot tastes vaguely sweet. Ask any 3 year old.
Why discuss this rather intemperate subject?
Cos I have been vacuuming snot out of my lovely daughter's nostrils with a hose-pipe connected to my mouth.
We have walked on the moon, we hold the world's knowledge in a pocket-sized computer, but we still haven't figured out how to get boogers out of tiny nostrils. This is a problem.
Babies can only breathe through their nostrils (mouth-breathing is a sadly acquired trait) and when those nostrils are blocked, they stop eating and sleeping. You may not realise this, but eating and sleeping are the only things babies want to do, hence the snot-vacuum. It's a little bulb that inserts into her nose (she loves this about as much as you would) and connects to a flexible straw. The straw connects to my lips. To prevent liquid mucus from entering my mouth, a thin paper "filter" is poked between bulb and straw. It works about 40% of the time.
I shove the bulb in and start hyperventilating so I can generate as much suction as possible without passing out. A chunk materialises in the bulb, Bub's cries get clearer (and LOUDER) and then we calm her by poking a nipple in her mouth. Mine, for what it's worth.
The past few days, I've been repeating this procedure every 2 hours. Bub hates it, I hate it and Mr G gets queasy just watching. The glamour and reward of parenting.
Makes me nostalgic for work, where the suction is connected to the wall, and I rarely get bitten after making someone feel better.
PS: Yes, I'm spelling it mucus. Mucus is the substance. Mucous means "pertaining to, or related to mucus". Look it up.
Thursday, January 22, 2015
itchy
Being diagnosed with post-partum depression is a lot like being told you have head lice.
Even though you know it's common and treatable, it's still pretty embarrassing, and you wouldn't be in this position if you didn't have a kid.
That said, it's also a relief.
It's nice to know that you're not just an incompetent mother. Or that your feelings of failure are pathologically disproportionate. It's nice to know that feeling out of sync with all the other mothers at Baby Time isn't just your personality.
Of course, much like head lice, acknowledging the problem is only the first step. Now we get out the medicated shampoo, the gloves and the teeny tiny comb, and start working the problem out. With time, you'll be able to show your face in public again, confident that you're going to be ok.
Bring on the permethrin.
Even though you know it's common and treatable, it's still pretty embarrassing, and you wouldn't be in this position if you didn't have a kid.
That said, it's also a relief.
It's nice to know that you're not just an incompetent mother. Or that your feelings of failure are pathologically disproportionate. It's nice to know that feeling out of sync with all the other mothers at Baby Time isn't just your personality.
Of course, much like head lice, acknowledging the problem is only the first step. Now we get out the medicated shampoo, the gloves and the teeny tiny comb, and start working the problem out. With time, you'll be able to show your face in public again, confident that you're going to be ok.
Bring on the permethrin.
Thursday, January 15, 2015
whoopsadaisy
My post-secondary education has been a meandering journey. It's taken 14 in 8 different cities across two continents. You would think that somewhere in that time, I would have had a real job interview. Nope.
The last time I sat in front of someone and answered questions about my "greatest weakness" and "communication skills", I ended up wearing a green apron and making extra-hot lattes for Gordon Campbell. It's been a while.
The medical interview should, theoretically, be a highly structured process. I envisioned walking into a room with a long table, 2-3 suit-clad members of the team facing me. They ask me about my experience with critically ill patients. They ask me how I feel about the latest BMJ on tranexamic acid in trauma. They ask if I've ever sexually harassed the nurses, or how I would handle interpersonal conflict.
In reality, my phone rings at 10am. I am still in bed, in pajamas, feeding Bub. She's latched on and I'm fumbling to answer the phone without dislodging her, which would result in screaming.
I answer the unidentified number and the friendly voice on the other end says, "I know you were going to call tomorrow, but I'm going on vacation and wanted to make sure we caught you - what do you want to know about our ER?"
The chief of this community hospital is excited and engaging, promising me solid billings and access to a CT scanner overnight (luxury!) plus a good relationship with nursing staff and "tons of support during the early days".
At the end of his spiel, I say, "It sounds great - I'd love to apply for the position..."
He says, "Oh, ok. Send me your references - if there are no surprises we'll get your paperwork started!"
Just like that?
Just like that.
Now I'm nervous. Was it too easy? Am I missing something?
The larger sister hospital to this one has also asked me to come in for a tour and "chat" where they would suss me out. Do I wear my interview suit? Can I bring the baby? Is this an assessment of my suitability or are they trying to sell me on the joint?
Despite all the education, all the planning and all possible signs pointing towards this day, I am still in shock.
I think I have a job.
The last time I sat in front of someone and answered questions about my "greatest weakness" and "communication skills", I ended up wearing a green apron and making extra-hot lattes for Gordon Campbell. It's been a while.
The medical interview should, theoretically, be a highly structured process. I envisioned walking into a room with a long table, 2-3 suit-clad members of the team facing me. They ask me about my experience with critically ill patients. They ask me how I feel about the latest BMJ on tranexamic acid in trauma. They ask if I've ever sexually harassed the nurses, or how I would handle interpersonal conflict.
In reality, my phone rings at 10am. I am still in bed, in pajamas, feeding Bub. She's latched on and I'm fumbling to answer the phone without dislodging her, which would result in screaming.
I answer the unidentified number and the friendly voice on the other end says, "I know you were going to call tomorrow, but I'm going on vacation and wanted to make sure we caught you - what do you want to know about our ER?"
The chief of this community hospital is excited and engaging, promising me solid billings and access to a CT scanner overnight (luxury!) plus a good relationship with nursing staff and "tons of support during the early days".
At the end of his spiel, I say, "It sounds great - I'd love to apply for the position..."
He says, "Oh, ok. Send me your references - if there are no surprises we'll get your paperwork started!"
Just like that?
Just like that.
Now I'm nervous. Was it too easy? Am I missing something?
The larger sister hospital to this one has also asked me to come in for a tour and "chat" where they would suss me out. Do I wear my interview suit? Can I bring the baby? Is this an assessment of my suitability or are they trying to sell me on the joint?
Despite all the education, all the planning and all possible signs pointing towards this day, I am still in shock.
I think I have a job.
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