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???
Tuesday, November 10, 2015
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.
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