Blog of The Anonymous Clerk

New location

2006-12-05T12:52:00.000-08:00

Sory for the late, late notice but I'VE MOVED! I'm a resident now, blogging at jamesloganmd.com. Thanks for looking!

Butt pus

2006-03-20T07:52:00.000-08:00

So there I was, on my surgery sub-I, scalpel poised in hand while the resident spread this guys butt cheeks for me. The unfortunate man had an abscess just to the left of his anus. I numbed the skin with lidocaine and made my incision. To my great dismay, nothing came out. I extended the incision a bit farther south and - Bob's your uncle - glorious white fluid came squirting out. We emptied out the cavity, packed with iodoform and put a dressing on it.
Afterwards, the intern told me to thank the resident for letting me do it. "Yes," I thought to myself. "Thank you. Thank you so much for the opportunity to drain pus out of this guy's ass!" It actually is kind of satisfying. It's painful for the patient while you're doing it, but they are so grateful afterwards.

Uncertainty

2006-02-27T06:37:00.000-08:00

Match day is now 17 days away. I start my surgery sub I today, so that should take my mind off things a little. I do have a few things like yearbook photos to take care of before then. I heard a couple of my classmates discussing a skit they would be participating in. I didn't even know we had a skit night scheduled. I do regret, somewhat, not being more involved in our class. It happened to me in college and it happened here - both times related to having a break-up with someone in the class. That settles it then...no dating my fellow residents next year! Done.
I really don't know what this months holds for me. I hated my 3rd year core surgery rotation. I can't believe this will be as bad as that. But we'll see. The end of thsi month has the potential to be glorious. But it could also just suck depending on where I will be matched come March 16th. Seems all there is for me to do is wait.

2nd look

2006-02-17T10:36:00.000-08:00

Feeling generally better about life over the last several hours. Just went for a second look at one of the programs I applied. Very reassured that it's a place where I would be happy. Have to go back to work again this evening. Had a headache of a night last night. Good kind of headache though. Still have to pay bills, exercise more, get my life together, blah, blah, blah.
Will use complete sentences in next post.

Bikes and back pain

2006-02-10T06:30:00.000-08:00

Man, it's been a long time since I've visited!
I just printed out an article on low back pain. It cost me $2.30 so it better be worth it! I could've saved $1.30 by leaving out the references and figures. I definitely don't want the references. But, I supposed I get the figures this way.

I'm going to the International Motorcycle show tonight. YES! I'm stoked. We have a lecture in 1/2 and hour, so I'm taking advantage of a little down time to blog. Then lecture. Then, the rest of my day in the ER then...MOTORCYCLES!

There are many event in my life that the reader may like to catch up on. Step 2 CK last week, Step 2 CS next week, graduation breathing down my neck, etc., etc. No time now though.
Thank you to all who still visit my blog. I love you all! And I promise to move to a nicer place next year. ;)

Catching up

2005-12-05T19:57:00.000-08:00

I've been getting the urge to blog more and more often lately. My glands are starting to secrete those creative juices again. And there are things in my life going on that are significant enough to blog about now.

Let's see...
I examined a woman with a visual field cut the other day. Never seen one of those before. A right homonymous hemianopsia. She had apparently had this all her life and just not known it. The resident told her not to drive. Her response was, "I haven't been driving for years."
"Why not?"
"I'm one of those drivers that everyone honks at. I get into accidents. I thought I just wasn't a very good driver!"

Finally got our eval's back from my family medicine rotation. They were fine, but not stellar - which is what I expected. I didn't get quite incensed by one of my evaluator's comments though. A second year resident marked 'inadequate performance' in the category of 'displays appropriate, professional behavior.' That gets me angry. If my H & P's are bad, or if my fund of knowledge needs improvement, fine. I can work on those things. And a resident is in a better position to judge my performance in those areas. But what gives her the authority to call me unprofessional? My opinion on what is or is not professional is every bit as valid as hers and I claim that I displayed no unprofessional behavior whatsoever on that rotation. The reason she gave for her assessment was that I, apparently, questioned her physical exam finding in front of a patient. First of all, I don't know what the fuck she is talking about. Second of all, if I did express a difference of opinion (maybe I said "I don't hear a murmur" when she said there was one") there is nothing wrong with that! In fact, it would be unprofessional to simply go along with what she said without making my own assessment. If you don't want to be around people who are going to have a different opinion, don't rotate with medical students! And good luck never being questioned in the rest of your training!
Had to get that out of my system. I think I'll try paging that resident at some point and ask her what she was talking about. But she probably won't even remember.

Vicious cycles

2005-12-01T08:50:00.000-08:00

I think I've grown too comfortable with the amount of debt I've acquired. I'm comfortable enough that I don't mind taking on more (there's just so much of it already). And, since I don't mind taking on more debt, I can use my loan money to buy new things. The more things I buy, the deeper in debt I become which, in turn, makes me more comfortable taking on new debt (I mean, there's just so much already).

Ain't technology grand?

2005-11-28T11:30:00.000-08:00

Well, my attempt at blogging from the men's room at the hospital was unsuccessful - something about the browser settings on my PDA. So, I'm blogging from the library during this little spot of free time that I have.
To briefly update you all...I did, in fact, take the GRE - even though plans of applying to grad school have basically fallen by the wayside. I only had one person to write a letter for me and I would've felt like a tool asking people with whom I haven't worked in over 4 years to write me recommendation letters when it was highly unlikely that I would accept a spot in a philosophy PhD program at Stanford and unlikelier still that I would be offered such a spot to begin with.
Residency interviews are fun. I've been to three so far. It's just like rushing a fraternity all over again. Everyone is on their best behavior. I haven't been offered interviews at my top choices, though. More accurately, I haven't been offered interviews at the most prestigious places to which I've applied. Whether or not those places would've fallen at the top of my rank-list is a different story.
Skye was in town a couple of weekends ago. We had a very nice time together. She may come again for New Year's. My friend's family has some land up north where we have a tradition of spending New Year's. Even if she doesn't join us, I'll be going out there for some interviews in the SanFrancisco area in January. As fun as neurology is - and we do have some fantastic residents right now who really make it a pleasure to come into work - I can't wait for it to be over. 3 more weeks, then I'm off for Christmas then off for interviews during January. I might move the blog to a newer, better place during that time. Keep checking!

If residency can be like this, maybe I'll do it after all

2005-10-19T09:57:00.000-07:00

I'm loving my REI rotation (reproductive endocrinology and infertility). The doctor I'm working with does a few procedures here and there and sees maybe 5-6 patients a day. She gets in at 8:30am and is gone by 2pm every day. She doesn't follow her patients throughout pregnancy, is never on call, and rarely has patients in house to take care of. Today, she cancelled all her appointments after 10:30 so she could take her son to the airport. Which is what I'm in the lab blogging at noon on a Wednesday. I totally want her job.

So far all the programs that have gotten back to me (4 in all) have offered me an interview. I'm looking forward to the interview process and am keeping an open mind.

Drug rep lunches

2005-10-05T12:41:00.000-07:00

I do always enjoy it when, as a total bonus, we get a free lunch provided by our friends at Merk or Phizer. This is why I need to go into medical ethics. Who decided that this is ok? Since when do medical professionals allow their education to come from those who have a specific vested interest in what treatment decisions they're going to make? Pretty soon all of medical school will be free. Doctors' education will be fully sponsored by Lily or whoever and it will then be up to the patient to do some research to find out which company owns his doctor. It's totally ridiculous.

Blogging in public

2005-10-03T11:42:00.000-07:00

So, as the reader can probably tell, I'm becoming more and more open about my blogging. I'm also now blogging in more exposed places like the library (that's where I am now). Pretty soon I'll be fully un-anonymous.
Have some stuff to say but I've got to go because this girl, whom I was, coincidentally enough, calling just 5 minutes ago is at a computer acros the way. I have to go talk to her.

Breakfast burrito

2005-10-02T14:56:00.000-07:00

I know, I know, I've been a lazy bum not updating for ages and ages. I'm still here - still trying to figure out what to do with the rest of my life. I just talked to my would-be philosophy mentor and he agreed that he and I need to meet so that he can dissuade me from pursuing a PhD. in philosophy. I'm going to apply anyway. What have I got to lose, right? The residency application is already in so, as far as that goes, all I have to do is sit back and hope that some programs want to interview me. Or, maybe I'm hoping that nobody wants to interview me. Please, if any of the 4 or 5 people who still read this are doctors - tell me, was it worth it? Any regrets? Are you happy?
Right now I'm doing a reproductive endocrinology and infertility elective. It it quite cool. Perhaps the coolest thing I've done so far in medical school. The attending with whom I work has a good job, there's no denying it. Even just ordinary obgyn attendings have pretty good jobs, I think. But it's not glamorous. It's not a dream job by any stretch. Even if it were, I'm just not sure I see myself getting through residency - for a variety of reasons. But the applications are in. There's still plenty of time to recommit myself and give residency a go after all if other job options turn out to be to bleak.

Ok preview of what's to come:
a) I promise to write some stuff about all the cool infertility things I'm doing now
b) Next Monday, I let you know what advice I get from the man whose job I'm after (medical ethicist)

P.S.
The post's title refers to what I ate for brunch this morning at a neat little restaurant called Jane's at the corner of Courtland and Paulina. I am something of a breakfast burrito connoisseur and theirs is truly excellent.

Checking in

2005-09-03T20:39:00.000-07:00

Life can be so interesting. Just got the move done. I'm in the new place now with a new roommate - an old high school friend. My computer decided not to boot up when I turned it on there. My friend, B.J. showed me how to do some fancy things to get the registry fixed. We're halfway there. It boots up, at least and I can access my data. So, all is not lost. Of course, I need my computer for a hell of a lot more than accessing old papers I've written. Many hours of work and research on what to do with my life lie ahead. This post is really just to let those of you gracious enough to continuing this blog know that I am indeed still alive and blogging. I have internet access at the new place in a couple of days. More regular blogging to come.

4 more days...

2005-08-15T21:12:00.000-07:00

Friday is my last day on this rotation.

I hate leaving for work in the dark and coming home in the dark. 14 hour days - woohhoo!

Reading: Harry Potter and the Sorcer's Stone and loving it. If life doesn't intervene, I should be through the series by the time book #7 comes out.

Rupture

2005-08-09T21:32:00.000-07:00

Thursday, August 4 - 1:27am. Stanford Hospital labor and delivery ward.
34 year old Sally McFarland has been trying desperately to push out her second child for the better part of an hour. The baby's visible head suddenly retracts and a gush of blood runs out of Sally McFarland's vagina. The attending obstetrician, Lina Sanders diagnoses a uterine rupture and the patient is rushed to the OR where a laparotomy is performed and her baby removed. Dr. Sanders attempts the repair and, at around 2:41am, she calls Dr. Carl Chang - the gynecology oncologist for help. The father remains in the OR. The patient is awake and has an epidural; she is numb from the waist down. Dr. Chang successfully completes the repair. The baby is fine.

Monday, August 8 - Stanford Gynecology Oncology Clinic
DR CHANG: So, I'm attempting this repair, and the OB attending is watching everything I'm doing and then going over to the other side of the curtain to tell the husband what's going on. That's totally inappropriate. I mean, how am I supposed to work in that kind of environment? She leaves me this disaster and I'm supposed to just fix it without being able to talk about anything. She had sewn the upper part of the vagina directly to the lower uterine segment. Her cervix was displaced laterally into the abdomen. It would have been much safer to do a hysterectomy rather than try and sort out the mess she made. She kept asking, "What do you think Dr. Chang? How does it look?" But you can't say, "It looks like someone screwed this up royally" with the husband in earshot. "Oh, he's the expert," she kept telling them. Yes, 'the expert' is here to fix everything! What if I hadn't been able to fix it? The patient could have bled out right there. And who's the husband going to sue - THE EXPERT! The patient should have been asleep and the husband should have been out of the room.

Monday, August 8 - Stanford Hospital postpartum floor
DR SANDERS: That uterine rupture was really something. I don't know how Dr. Chang figured it out. It was just like hamburger meat in there. Her cervix was all over the place. He took down one of the repairs I had made and put it back together differently. He should really watch some of his comments, though. He's used to his patients being asleep, I guess. At one point he said, "This reminds me of what happened to my really expensive vase in the last earthquake. Some $12 piece of junk fell on it and I had to glue it back together." You can't say stuff like that in front of the patient. He's an excellent surgeon, but I think his bedside manner could use some work.

Moral: No one has a monopoly on professionalism.

Kite fest

2005-08-01T19:44:00.000-07:00

Thanks to all who responded to the previous post. Things are actually going quite well over here now. That's thanks, in large part, to the incredible team I'm working with. They're super-awesome in terms of keeping the medstudents in the loop and allowing us to participate. They're also really nice and easy to ask questions of. I won't lie though, I do still find myself looking over at the paramedics or the drug reps and asking myself, "That would be a pretty good job, right?" The answer, or course, is that in some ways, those jobs are indeed way better. In other ways, clearly worse. The problem is, that up until now, I've never really sat down and thought - in any kind of mature manner - about what I want to be when I grow up. One way or the other, I'm going to finish med school. So, I have just under a year to figure it out.

It's wonderful to be in the same geographical area as Skye for awhile. Friday we had some excellent sushi and went for drinks afterwards. Saturday we got lots of shopping and errands done and then watched the second semi-final match of the women's Bank of the West Classic. Kim Clijsters won - <sarcasm>big surprise</sarcasm>. And on Sunday we met Skye's parents for brunch, they lent me Skye's old bicycle (so I can get my ass across campus to work every day) and went with some friends to a kite festival in Berkeley.

And it was a pretty good day today.

Ok, new assignment:
For the sake of completeness and objectivity, any doctors out their regret their decision to go into medicine? Wished you had done something different? Tell us.

Cry for help

2005-07-27T21:36:00.000-07:00

Here's what I'm looking for. I looking for success stories - inspirational stories. Any attending physicians or residents who happen to be reading, this is a message for you. Tell me how residency really wasn't that bad. Tell me how much you dreaded going from being a relatively responsibility-free medstudent to a responsibility-laden physician. Tell me how rewarding your work is and how you could never picture yourself doing anything else.
I'm doing an away rotation at Stanford hospital. I'm pretty sure I saw Graham there today. I just spent 3 successive 14 hour days in the hospital. The shuttle here begins running after I've gone to work and stops running before I can leave. There's some pretty cool stuff that I've gotten to be involved in but in many significant ways IT SUCKS! Is this really what I want to be doing? I'm going to give up 4 of the potentially best years of my life for THIS? I'm a 4th year now, so it's getting to be about that time. My days are numbered. Doctors? Is it worth it?

Partay

2005-07-22T23:56:00.000-07:00

Not much time to write a detailed account of my evening. I have to pack as I leave for Cali tomorrow. Went to old roommate, Mike's, birthday party tonight. It was pretty fun. Lots of people who I hadn't seen in a long time, lots of people who I'd met maybe once before. Not too much drinking as I had to drive home. Katy was there. The story with Katy is that she seems to be completely and utterly uninterested in me. The last weapon I have in my arsenal is to completely ignore her. This strategy was thwarted by my friend, A, who invited her to Sunday brunch at my place last week when about 85% of the motivation behind my hosting Sunday brunch in the first place was specifically to not invite Katy. Today I found out that she has a job now - working in a battered women's shelter. Baaahhhh! I can't stand it. She's so fucking good! I hate it. Can't she do something mean or selfish just once? Could she please give me any reason at all not to be completely in love with her?
Anyway, I'll be seeing Skye tomorrow. That'll be nice. I would say the relationship is doomed, but I've been saying that for a year now. I am looking forward to seeing her.

Other blogs

2005-07-21T12:41:00.000-07:00

What is it about reading other people's blogs that so inspires one to blog themselves? Why is it that I didn't realize until just now that the word, 'blog' can be used as both a noun and a verb?
I only have time for a quick update as there are many things on the agenda for today - i.e. put some clothes on, go get lunch, work on my CV, write a personal statement. We just had a meeting last night detailing everything that we need to do in order to apply for residency programs and enter the match. Fun stuff.
As far as what I've been up to lately...M3 year ended almost 5 weeks ago. That was followed by a fun debaucherous week with my friend in Columbus OH, a second fun weekend which included going to Summerfest in Milwaukee, WI and to the aforementioned friend's beautiful summer home in Tomahawk, WI. Katy was there. She made sure to be friendly but also to take every available opportunity to make sure I understood that she wasn't interested. I then had a week off - spent living with my parents - followed by 2 weeks of independent study anatomy lab (I did the female pelvis). And this is my final week off before going back into the hospital for a 4 week away rotation California.
It's a good thing I have medical school to keep me rolling along. Over the past week, I have learned that, if left to my own devices, I will basically do nothing useful with my time. I've basically spent the last week playing games online and masturbating here in my parents big, lonely, empty house. Probably, once I'm busier, I'll have more energy to blog. Thanks, those of you who continue to stop by!

Ladies' golf

2005-07-15T00:50:00.000-07:00

The fact that Michelle Wie is only 15 is really getting me down.

maps

2005-06-28T00:24:00.000-07:00

Google maps is incredible...I just found my house!

Moving out

2005-06-22T21:56:00.000-07:00

Ugh - I hate moving. Plan is to stay up all night cleaning and packing, take care of canceling utilities and having mail forwarded tomorrow, move out and then off to Columbus OH on Friday. I'll blog again when my life has some semblance of order.

Pharmacist sues over 'morning after pill'

2005-06-10T14:11:00.000-07:00

I'm posting about this more because I want to bookmark it as an interesting ethical dillema than because I want to rant and rave about it. I think they're going to find in favor of the pharmaicst. They should. Maybe I'll write a post on why some other time.

Ekg's

2005-06-10T13:46:00.000-07:00

So, my intern has really been wanting to teach me something. We've been playing tag for a couple of weeks now, trying to arrange a time when he and I as well as the other 2 students are all free. The topic was Ekg findings in acute MI (heart attack). He talked to us about ST elevation MI, non-ST elevation MI, Q-waves etc. Coincidentally enough, a patient on our floor had an MI today. After our teaching session, he took us by the room to look at the Ekg. The first one was normal. A few minutes later there was some concavity between the QRS complex and the T-wave, then the ST segment became about the same height as the peak of the T-wave and finally, no discernible T-wave at all. Pretty cool (not for the patient, of course, but for us). Even the senior resident had only seen ST elevation like that a couple of times before because, whenever it happens, the patient goes straight to the coronary catheterization lab.

Jen's in town. I just talked to her last night. Suddenly, I'm not that enthusiastic about having dinner with her family tomorrow night. I think she's still staying at my place tomorrow - although on the phone just now she told me her parents actually didn't forget to book a place for her and it's not necessary for her to stay with me. Whether she stays or not, though, is kind of immaterial. If there was any chance of us sleeping together at all, it would've happened a long time ago. Of course, that won't stop me from getting my hopes up.

No pussy for you!

2005-06-05T02:35:00.000-07:00

I feel like God is toying with me. Remember high school? In high school, you had a crush on one girl at a time. This was good because it allowed you to focus all of your mental and emotional resources on working up the nerve to pursue that one girl. That was then. This is now and thins are infinitely more complicated. Let's take inventory:
There's the girl who most of my heart still belongs to. She broke it sophomore year in college and left the store without bothering to pay.
There's the love of my life. We're actually good friends now. And even though she's dating another person of similar race and culture now, I get the feeling that she would allow me to pursue her if I wanted to. Thus far, I haven't.
There's Skye. She was in town last weekend. She and I connect really well. But the god awful sex really poses a barrier to being happy while we're physically together. The distance and lack of any long term plan to be in the same city is another barrier to our relationship. And finally, there's the fact that I'm just not as into her as she is into me.
There's Rachel - a high school friend who I met at a barbecue tonight. My good friend and I have pined for her since 8th grade. At the barbecue, she was telling me about this abdominal pain she's been having. I asked her some questions about it and gave her my opinion. Unfortunately, I didn't get a chance to examine her. She has a long-distance boyfriend now. I could fall in love with her faster than you could say, "nevergonnahappen."
After the barbecue a bunch of us went to this party. I met this tall, somewhat cute, somewhat voluptuous girl there who happens to be a teacher. We talked most of the night. I think she was really into me. I was thinking about how to make myself scarce for most of the conversation. She offered to give me a ride home. I decided to stay at the party but got her number.
About five minutes after she left, my friend Constantine and I met this girl who was extremely cute, extremely fun to talk to and highly flirtatious with both of us. Turns out, she used to be a stripper. I think she liked me better. But Constantine was making more of an effort. I thought he deserved it more and I didn't want to cock-block. He took her home. And that was pretty much the evening.
And then there's Jen. I met Jen during my junior year abroad. We were really close friends. I had a thing for her for awhile, but she was dating this native guy and nothing ever materialized. I haven't talked to Jen in years. About a month ago I got a random email from her and we started corresponding. Turns out she'll be in town next week for her brother's graduation. "Cool," I said. "We should hang out." Next email from her is an invitation to her brother's graduation diner. "That sounds like fun," I said. "I'd love to go." Next email from her says something about not having a place to stay when she's in town and asking if she can stay at my place for a couple of nights. "Sure," I said. "I usually sleep on the futon, so the bed is all yours." Should I have said that? Did she want to hear something more along the lines of, "I have a really tiny place, but I think I can squeeze you in for a night or two?" Or maybe something more like, "Yes, I'd love to relive the past with you for a couple of nights and have old friend comfort-sex with you while you're here." I have no idea what she's thinking. I'll let you all know how it goes. Jen is a wonderful and beautiful girl. But she is extremely intelligent and also highly manipulative. She's dangerous. She has a real knack for getting guys to fall in love with her. Allowing her back into my life at all is basically playing with fire. But, what the hell; I've never been the cautious type.

And now, it's 5am and time for sleep. No pussy for me tonight :(

Addendum 6/7/05 @ 10:45pm
I can't believe I neglected to mention the lovely Katy! Saw her at brunch on Sunday. So cute, so genuine, so free-spirited, so quietly attractive. I'm pretty sure she's coming up to my frineds summer home on the 4th of July weekend with us. I'm counting the days.

Longing

2005-05-29T12:57:00.000-07:00

Skye's in town. I'm at the hospital - on call today. She's lonely at my place. It's that point in the year where each day is one day closer to the last day of the year. I'm counting them. There are 19 to go. I realize the posings have been a little thin lately. I promise lots of good stories in 19 days.

Sick

2005-05-21T19:36:00.000-07:00

In it's inevitable progression to full blown bronchitis, what began as a simple sore throat (pharyngitis) now seems content to linger in my upper airway (laryngitis). I coughed all the way through Revenge of the Sith last night and woke up unable to speak this morning. I'm pretty miserable.
I took the day off last Thursday. It was the first sick day I've taken throughout the whole of my M3 year. And I got some serious attitude from my attending when I came in on Friday morning. I had paged the senior resident to let him know I'd be gone. He, as I had assumed, had let the rest of the team know. Friday morning my ice-bitch attending Dr. Schiffer says to me, "Sorry, you need to tell me directly if you'll be gone. I'm the head of the team and I didn't find out until 1pm yesterday."
The response going on in my head went something like, "Well, you were in clinic until 1pm. You weren't even on the floor! Is there some reason you needed to know what your medical student was doing between the hours of 7am and 1pm? I'll tell you, if you want to know. I was, spiking temps and coughing my lungs out. What came out of my mouth was, "Of course, very good point Dr. Schiffer."
"Because," she continued, "it's really bad to miss a call day. I don't think I have enough information to evaluate you now. Are you even going to pick up any patients today?"
"Well, it is my last day. And I have to be at a clinical skills exam at noon...so no." "Oh, and Dr. Schiffer," I would like to have added, "I'm feeling better, thanks for asking."
And that was pretty much that. The clinical skills exam was pretty silly. It was just practice for Step 2 of the boards - an exam that the administration really doesn't want any of us to fail. We interview and examine actors who have been trained to portray a particular illness and give our impression. I hope I didn't make any of them sick. My cough had become pretty uncontrollable by midafternoon.

Thanks

2005-05-15T14:32:00.000-07:00

Thanks to those of you who dilligently continue to visit my blog despite the recent paucity of postings. I've been busy with my medicine rotation lately.
It's Sunday. I'm on call. It's 4:33pm. I've been done with my work since 3pm. Just waiting for my attending to show up so I can present to her and go home - go for a run, watch Grey's Anatomy, watch The Newsroom call Skye and go to sleep. Our current attending, Dr. Bayram, will be gone after today. She was so much fun. Dr. Bayram always says exactly what's on her mind, always wears very fashionable outfits (she has yet to repeat one in 3 weeks) carries a pink iPod next to her pager and walks around like she's queen of the universe. And she teaches more than any other attending that I've worked with. She's planning on taking our team out for drinks at one or our city's poshest bars next weekend. I think I'm in love with her. Unfortunately, she's happily married with an 11 year old daughter. But, I'll go anyway. It's always fun listening to her spar with the equally blunt Chinese intern.

Follow up on the liver guy and On pathologists

2005-05-12T20:21:00.000-07:00

It looks like our yellow guy with liver failure is going to make it! He was in the ICU but is back on the floor now. The GI docs had given him a 10% chance of survival. But he's recovering. We're still waiting for the biopsy results. Those pathologists have an amazing job. You never see them, they never see you. And yet, the most crucial decisions made in medicine are, more often than not, based on what the pathologist says. They hide in that smelly lab in an obscure part of the hospital quietly handing out diagnoses through the lens of a microscope. They are a weird combination of Santa Clause and the Grim Reaper. They leave gifts for some, like benign fibroadenoma or mature teratoma and death sentences for others, like Huntington's Disease or glioblastoma multiforme. What will it be for my little yellow guy with the big diseased liver?

Post-call

2005-05-07T20:37:00.000-07:00

My friend, J. invited me out last night. His girlfriend had just graduated from pharmacy school and they were celebrating at a local bar. I didn't really have the time to spare, but I went anyway. Alas, so many hotties danced, mingled, flirted, made out with random guys and yet there was so little time for me to talk to any of them. I met the dangerously cute roommates of my friend's girlfriend, I met this girl what was a swimmer, graduated at the top of her pharmacy school class and happened to be the organizer of the party and I met this guy who won our city's annual 8K race - no small feat in a field of 50,000. It was a good night. And it was a good call today. I saw two very interesting patients and got out by 8pm. Tomorrow I have to go in for post-call rounds. Hopefully we'll be out by noon so I can get the apartment cleaned up before the family comes over for Mother's Day dinner. All in all, not bad for having Saturday call and NO days off this week. If life never gets any worse than this, I can definitely handle it.

The God Squad (aka liver transplant team)

2005-05-02T15:32:00.000-07:00

I arrived at the hospital this morning to find that my liver guy had been taken to the ICU for a GI bleed. I went to check on him before I left today. There was a note in the chart from the liver transplant team. "We evaluated the patient. He is not a candidate for liver transplant at this time. If he abstains from alcohol for 6 months and is still alive at that time, will reevaluate." This bothers me on a couple of levels. First of all, I should've been able to get the history of alcohol abuse from him. I as well as several other doctors had asked him how much he drinks multiple times and each time the answer had been '3-4 beers/week.' As it turned out, he had been depressed for about the last year over his inability to find a job - this difficulty no doubt arising from his congenital forearm abnormality. In retrospect, I totally should've seen it. I should have asked the CAGE questions. But, live and learn. Knowing that he used to drink a liter of wine per day up until the point where he turned yellow would've saved us some tests, but wouldn't have ultimately changed our management at all. Secondly, "will reevaluate is 6 months if the patient is still alive?" HARSH! Aren't you supposed to conveniently forget that your patient is an alcoholic when it comes time to put him on the list for a liver transplant? Apparently not. Doctors really do get to play God.

Does NPO include holy food?

2005-04-30T19:13:00.006-07:00

I was on call yesterday. My first patient was a 25 year old Polish immigrant presenting with a 3 week history of jaundice and fatigue. After extensive work-up, we still don't know what's causing his hepatitis. It could be alcoholic cirrhosis, autoimmune hepatitis, Wilson's disease, hemochromatosis as well as a few other things. The GI docs said he would almost certainly need a liver transplant if he is to survive - which almost certainly won't happen since his current immigration status is "illegal alien." We made him NPO (nothing by mouth) today in order to rest his stomach. With his liver-failure induced coagulopathy, a bleeding ulcer could be devastating.
The patient's mother came by with the family priest this morning. I happened to be seeing the patient at the time and struggled to explain the patient's condition in plain English. My broken translation from medical-ese to English was then translated from English to Polish for the mother's benefit. At the very least, I'm pretty sure she comprehends that her son is very sick and might die.
Here's my dilemma: when I was done talking to the mother and writing some notes, the priest approached me and asked if the patient could take Holy Communion. Aw jeez...I turned this over in my mind. What if I say 'ok' and he bleeds out today from a massive ulcer? On the other hand, it's just a little bread wafer...and he is on a Protonix drip (a drug that inhibits acid secretion). And if he's going to die anyway, why add whatever additional emotional/spiritual angst that being denied Holy Communion may cause? Here were my choices of response as I saw them:

a) No, absolutely not. It is very dangerous for him to take anything by mouth.
b) It's against our medical advice, but ultimately the patient must decide from himself.
c) Sure, go ahead.
d) That's fine, I just need to verify that you are properly credentialed as a priest. He can take it as long as it's truly the body of Christ. If there are any carbohydrates in it at all, he can't. Are you properly trained and authorized to transubstantiate?
e) Hold on, while I page my resident and ask.

What would you do?

Grand rounds: edition 31

2005-04-26T20:01:00.000-07:00

This week's Grand Rounds is up at Dr. Tony's place.

Delivering bad news

2005-04-20T11:17:00.000-07:00

The two young ladies wrang their hands and fidgeted in their chairs. The expression on my face told the story that they didn't want to hear and they embraced each other tightly, sensing that all hope was about to be ripped away. Their worry and anxiety filled the poorly ventilated little room like a cloud. I wished their was something better I could do - something to relieve their suffering. I wished I could flip a switch that turned on an exhaust fan, blowing their grief out into afternoon air. But today, the unpleasant task fell on my shoulders.
"Hi," I smiled, shutting the door behind me. "I'm student doctor, J. I understand you're here to talk about John Stanley. May I ask how you are both related to Mr. Stanley?"
"We're his daughters," they answered together.
"I see. Well, as I'm sure you know already, your father came in yesterday afternoon with a significant myocardial infarction. His cond-"
"A what?"
"Your father had a heart attack."
The elder daughter who was sitting farther away began to sob. "Oh my god. Is he...is he ok?" The younger, nearer daughter stared at the wall and became silent.
"No, he's not ok." I fought back the urge to sob myself. "His condition worsened overnight and he became hemodynamicaly unstable."
"So, what does that mean? Is he..?"
"He's dead."
Younger daughter broke her silence and turned to me angrily, "But what happened? They said everything was going to be fine."
"I'm sorry you were told that. But, unfortunately, his condition was worse than we had initially realized." They held each other and didn't seem much in the mood for talking anymore. I didn't want to interrupt their grieving, but I was running out of time. "I'm sorry to have to bring this up right now but, with your permission, we'd like to do a post-mortem examination."
"You mean an autopsy?" The older one had calmed down a bit.
"Yes. Your father was 61. So, given his relatively young age for this condition, we'd like to find out exactly how diseased his vessels were and how far the infarct had progressed. It's helpful to us from an educational standpoint and it may also help identify any epidemiological factors that played a role in your father's death."
She stared at me blankly. "Well, what happens during the autopsy. I mean, you cut him all up right? We couldn't do an open-casket funeral?"
"The internal organs are removed and examined. There wouldn't be any external markings from the procedure so an open-casket funeral can be done without a problem."
"I don't know. I just don't see the point." There was a long pause. "Can we see the body?"
"Sure," I replied, standing up. "I'll have someone take you there right now." I offered my hand to each in turn, "I'm very sorry for both of your loss." We shook hands and I made my exit.

There was no body to take them to. This had all been an exercise that us third year medical students do as part of our internal medicine rotation. The two women were actors; there was no Mr. Stanley. The whole ordeal did little to ameliorate my dread of ever having to do this for real. I hope they thought I was ok, because this was pretty much the only practice I'm ever going to get. Next time it will be for real.

Rings and things

2005-04-19T20:49:00.000-07:00

The subject of engagement rings came up at brunch this Sunday. My personal view on the practice of giving a large chunk of carbon to the person you intend to marry has evolved over the years. The old me was adamantly opposed to the whole concept. What's the point? Aren't there about a million better things you could be doing with $8,000? And if you're fiance feels she must carry an additional 2ct around her 4th phalanx in order believe that you're committed to her, what kind of a relationship is it anyway? Amazingly, the entirety of Sunday's brunch crowd vociferously espoused the ideals of the old, naive me leaving the new, enlightened me as the lone voice to defend the norms of our culture.

The new me has come to understand that the ring is essential! It's not optional. Sure, it has no practical purpose but, c'mon people, we live in a society here! We do all kinds of things without any practical reason. What function does wearing clothes on a hot day serve? None! But we still wear them. If you want to live alone on a desert island then, yes, you have my permission to walk around naked and to forgo engagement rituals as well. But, in a social setting, everything we say and do makes a statement about who we are. Walking around naked - at least, in most neighborhoods - would make a statement that I'm not really prepared to make, a statement that is likely to get me arrested. Likewise, letting my fiance walk around without an engagement ring on would make a statement that I don't want to make about myself.

Here, off the top of my head, are just a few specific social functions that the engagement ring serves:

The ring as a statement of commitment
Ok, fine. But a poem can make an equal, if not greater statement of commitment at a fraction of the cost! Statement of commitment doesn't explain the need for a ring - read on.
The ring as a display of resources
Bearing young requires a huge investment of resources. If this guy can afford a ring, he can probably help bear the cost of raising your offspring.
The ring as a nonrefundable deposit
You mess around before, during or after the wedding and I'm headed for the nearest pawn shop. This insures that the man not only can, but will stick around to help raise offspring.
The ring as public statement of how much you're worth
This is why you give her a ring and not a trust fund or stock portfolio. If you don't send your mom a Mother's Day card, she doesn't assume you just decided to express your appreciation for her in some other way this year; she assumes you forgot. If there's no display of wealth on your fiance's finger, she (and the rest of us) assume you're worth nothing. The is important for us to know because, if we do decide to make a move on your lady, we need to know how many henchman you'll be able to hire to come after us.
Sheep mentality
Our teachers all told us that we shouldn't do something just because everyone else is doing it. What they left out is that just because everyone else is doing something, that's not a reason to avoid it. As social beings, we are biologically programmed to fear being left out. This is a good thing. In fact, we have a label for people who don't fear being left out, 'schizoid.'

So, yes, I have become a believer in what, on its face, appears to be a mere social exercise in pointless extravagance. It's a good thing, too. If it weren't for the minor hitch of not being able to afford an engagement ring, I probably would've been married 5 or 6 times by now.

Mischief

2005-04-16T21:23:00.000-07:00

I'm at my parents' house now - thinking that if I escape the distractions of my apartment I'll get some work done. In some regards, I'm a very slow learner because history has now repeated itself a healthy, almost obscene number of times and I still haven't gotten the message - I never get anything done here. How the hell did I ever do so well in high school? I guess the house was more functional back then. Everything my parents have done to the house since my sister and I left has served to make it less like a house and more like a museum. The big kitchen table we used to have has been replaced by a smaller table, with smaller less comfortable chairs. And the table cloth is so soft, it might as well be a bedspread.
The old dining room table with its friendly, rounded corners lots of open workspace has been replaced by a longer table with sharper corners and is covered by things that are either too soft or too breakable. The old, comfortable chairs have been replaced by wooden chairs with lots of 90° angles and even sharper corners than the table. The table was designed by the Amish (only made on a per order basis) and doesn't have a single nick or scratch on it..yet. I'm afraid to breathe on it! Not that I could get anywhere near it anyway - at least without stubbing a toe or scraping an elbow.
I'm bored! It's still early here - anyone want to go stir up some mischief? We can ring the next-door neighbor's doorbell and run away? Moon cars from the overpass? All suggestions welcome!

Whores, spleens, some ethics and a funny story

2005-04-14T19:39:00.000-07:00

Drug reps are so sleazy. I have to admit that, as a medical student, I love drug reps. They're always very attractive, very well dressed very polite and always super friendly. As a medical student, nobody looks up to you or has any reason to try to please you. The attendings, residents, nurses and office staff all have more knowledge and experience than you and most couldn't care less whether you live or die. But the drug reps, one the other hand, they're selling something. Therefore, it's their job to suck to everyone in the office - including, happily, me! They go out of their way to introduce themselves to us, to offer us their chair, to ask about what's going on in our lives...it's fantastic. And best of all, they are the providers of really nice lunches. I haven't bought groceries in 3 weeks because there is always plenty of great food left over from the lunch. I guess all sales people are whores to some degree but, with these drug reps, the lasciviousness just seems so much more palpable. It would be one thing if these drug companies tried to market directly to the consumer (which they do now, and I actually don't have much of a problem with that). But, since they're not allowed to sell directly to the consumer, they try to bribe us with free lunches and trips so we will prescribe their product. The reps provide lunch for the entire office staff even though it's only the doctors who they're interested in giving their spiel to and, to a lesser extent, the residents. I can't help feeling guilty though, if I eat without listening to why I should prescribe drug Y as a first line for all my black, diabetic patients with hypertension. I feel like I've just slept with a prostitute who split without letting me pay her. The whole thing, both the drug companies themselves and the doctors who allow the reps into their office - it's all a very seedy affair.

I felt my first spleen today. As I was about to see my own patient, my preceptor pulled me aside saying, "Here's a quiz for you. I want you to examine this abdomen." He yanked me into another room where there was a middle-aged man lying on the table with his shirt off. He wasn't terribly obese, but his belly fat hung loosely at both sides as if he was wearing skin that was too big for him. I did the whole exam and the only abnormal finding I came up with was an enlarged liver. I was one for two. My preceptor informed me that the patient also had a palpable spleen tip. I felt a second time and, sure enough, there was a spleen. Or rather, I felt what was apparently a spleen - as I had never felt one before. The unfortunate patient had hepatitis C. I thanked him for having an enlarged liver and spleen for me to feel and went back to seeing my patient.

I always get excited when we have a new patient in the office. It means I get to do the initial history and physical rather than having to go through a mountain of old, sloppy notes and lab results in order to find out what's going on. I went into the waiting room and called her name. She was a young, Asian lady sitting next to an older man in a long white coat who turned out to be her husband. Before I could introduce myself to the young lady (who looked about 17), white-coat man stopped me. "Actually, we'd rather just see Dr. Levin." As I later confirmed with my preceptor, this patient was the wife of a physician at our hospital and he'd called ahead to make sure that they wouldn't have to see any students or residents. It's sad but, as students, we rarely get to practice on the rich and powerful. We practice on the poor, disenfranchised sector of society. A physician doesn't want his wife to be seen by a student and BOOM - done. What if a patient seeking treatment at the free, county hospital didn't want to be seen by a student? Fat chance!

So, I'm about to do a pap smear on a 45 year old lady. She's in the stirrups without a very good view of what we're doing and, as I'm about to insert the tarnished, metal speculum, my preceptor looks down and says - "Man, that thing looks like it's been used over and over again."
An indigant, "Excuse me?" comes from the opposite end of the table. Evidently, the patient had not realized my preceptor was referring to the speculum. I cracked up while my preceptor explained and apologized profusely to the patient. She thought it was funny too.

True love

2005-04-11T20:58:00.000-07:00

I spent this evening with Min, my ex.
She's really the first ex who I've managed to develop a stable friendship with. We don't talk about her current boyfriend but pretty much any other topic is in bounds. It's ironic - she was so stupid to break up with me and yet those stupid things she does are part of what I love about her so much. I initially went over just to pick a CD of mine that she was borrowing. I brought left-overs from the drug rep lunch and we chatted awhile. I have no reason to try and impress or indulge her while I'm over there so my tendency is just to retreat into myself and let her drive the conversation around wildly - like a snowmobile on a slalom course - and hang on casually, trusting that we won't crash. And we never do. Sometimes her mouth is going a mile a minute, sometimes she's content to sit back and listen while I tell stories about myself. She and I used to fit each other like puzzle pieces, and we still do. She's been dating this new Chinese guy for over a year now - the same amount of time that she and I dated. Yet she tells me how much more comfortable she is sitting in silence with me, how nice it is that I go along with her crazy, spontaneous ideas whereas this other guy doesn't. She's betrayed her communist roots and thinks she's a Christian now (obviously the result of constant pressuring by Mr. Square loser Chinese guy), when she used to be my sweet, adorable atheist. The only reason she broke up with me in the first place was because I wasn't Chinese.
So there I was, taking a bite of the tiramisu she conned me into buying her, wondering what the future holds. I've promised myself that, before medical school ends, I'm going to ask her to marry me. She'll probably say 'no' and that's ok. Either way, I know I'll be happy - either happy with her, or happy as a single guy with a completely different agenda and lifestyle. I was her first relationship, so I always couldn't help but wonder whether she ever realized just how special what we had was. Now that she has some basis for comparison, I wonder if she'll make the decision to give me up again. If she does, it'll be for the best.

My weekend in list form

2005-04-10T23:16:00.000-07:00

Friday
- Clinic
- Errands/chores
- Poker with some ultra cool people who I just met
Saturday
- Our soccer team lost 2-1 :( (I nearly scored a goal...)
- Healthy brunch with some friends
- Chilling, lounging, procrastinating
- Movie with Skye. We do this long-distance date thing where we rent the same movie, one of us calls the other and we press 'play' simultaneously.' This time it was Donnie Darko. And it ROCKED MY WORLD! I wish I could say more about it, but I have to get on with this post.
Sunday
- Brunch at a Biker Bar with the Intelligentsia
- Returned videos and other assorted tasks
- Dinner with the folks
- Went to see Sin City with some friends. Great stuff, if your a comic book fanatic. Otherwise, I'd put it somewhere in the middle of my list of recommended viewing
- Writing this post

The lesser of 2 pathetic scenarios

2005-04-08T17:50:00.000-07:00

No date and no good plans for tonight, so I'm having the guys over for poker again. We play for low stakes but, invariably, people bring $20's and need change. If I've learned nothing else from medical school, it's that you should always try to predict future problems and avert them before they happen. Therefore, I took a couple of $20's to the bank today and asked for change.
"30 singles and 2 fives please." The attractive, young teller gave me a sly look. It didn't occur to me until I was already out in the parking lot - wad of bills in pocket - that, if I were the teller, I'd be wondering what some guy wanted all those singles for. It also occurred to me that, if I were the teller, I would have come to the conclusion that the young man asking for change was headed to a strip club that night. I dashed back into the back into the bank, driven by the sudden urge to explain myself.
"No, no. (gasping for air) The money's not for...I'm not going to a strip club tonight. I'm not even going out tonight. I'm just going to be home with some really lonely guys playing p- I mean...I'm going to a strip club."

Kant on medical education

2005-04-05T21:01:00.000-07:00

The next chart was about three times thicker than all the others. I grabbed it from the shelf and began to peruse. There were more than the usual number of labs. The patient had clearly been hospitalized recently. Pages of X-ray results, CT scans and MRI's showed no specific abnormalities. There was no discharge summary. The last progress note said something about colon cancer. As per my usual routine I thought: time to talk to the patient and get her story.
"Linda Carter," I called out. A tall, well-built African American man in his 50's wheeled, his wife, the patient, into my exam room.
"My wife is very sick and we've been waiting out there for over an hour and a half."
(Sigh) My last patient of the day was going challenge my ever-developing salesman skills. "I know. I apologize for that, sir. Dr. Levin has been extremely busy today."
"Well, you all need to run this clinic better. You think we have time to wait around here all day?"
"I'm sorry, I wish I had a better answer for you. But, I assure you, you have my full attention now. What can we help you with today?"
The husband, continued to speak for his wife who seemed to be in considerable discomfort sitting in her wheel chair, "She's doesn't have much of an appetite and has continued to lose weight. She's also dehydrated and has diarrhea."
"Ok, and when did this all start?"
"It's been going on since she got out of the hospital."
"I see. And what brought her to the hospital?"
This is where his patience ran out, "Don't you know? Don't you have her records in there?" pointing to the manilla tome on the desk. "We've told the story so many times. We really don't want to start from the beginning again. Can we just see Dr. Levin?"
At that very moment, the door opened. Relief. It was Dr. Levin. He took over, worked his magic and would give me the lowdown on the patient's medical history afterwards - metastatic colon cancer. Dr. Levin prescribed marinol for her appetite, dulcolax for what he believed to be constipation and encouraged her to drink fluid as much as possible. The husband shook my hand after we were all done saying, "Thanks, I hope I wasn't too hostile earlier." I understood completely and told him as much.

Philosophy 101: Kant believed we must always act "So that we could will the maxim of our action to be a universal law." Since we ourselves would never want to be treated as merely a means to an end, we could never will such treatment to be a universal law. Therefore, we must always view people as ends in themselves. What would he say about our system of medical education? I go into any patient encounter having nothing to offer except my sympathy and perhaps a meager amount of relevant medical knowledge. It is extremely unlikely that anything I do is going to affect the patient's treatment plan in any positive way. I am not there for their benefit, they are there for my benefit. I use them as learning tools. In order to become a doctor, I have no choice but to treat these patients not as ends in themselves, but as means to the particular end of furthering my medical knowledge and increasing my clinical experience.
4 years of studying philosophy as an undergrad and yet I have learned NOTHING! Could it be that medical education is inherently immoral? A necessary evil, if you will?

Grand rounds: edition 28

2005-04-05T17:00:00.000-07:00

A well organized and visually stunning Grand Rounds is up at Polite Dissent this week.

Follow-up

2005-04-03T21:01:00.000-07:00

About my last post, Garrison Steele said:

Ah, but did the good night melt into a good morning? :)

Unfortunately, the answer is 'no.' Tom and I did go back to their place. But medschool girl passed out on her couch and Tom has a "history" with the voluptuous roommate, so I didn't want to stick my nose in there. Besides, I had to get up for an 8k race today and needed all the sleep I could get (not that I wouldn't made the sacrifice). The race was less than thrilling. It just served to make even more apparent how out of shape I am. It took me 43:50. There was a time when I could run a 10k faster than that!
Brunch with the intelligentsia followed. Though none of them are practicing now, I happened to be the only one out of the 6 of us at today's brunch who wasn't raised catholic. I hadn't realized this before but, it turns out JP II was quite a fellow - worked in a forced labor camp during WWII, was an actor for awhile, traveled more than any other Pope. And he continued on with his Popely duties absolutely as long as his health would allow - some would say longer. We of the brunch crew have a mutual acquaintance who's actually traveling to Italy for the funeral. I'm not sure how she got tickets. She must have called in as soon as they went on sale because I hear they sold out in less than an hour. And, with that outrageous service fee, I think we finally have proof positive that Ticketmaster is the work of Satan.

On an entirely unrelated note, does anyone watch Grey's Anatomy? I'm not sure how I feel about this show. I'm glad there's finally a show portraying doctors as unsure of themselves and as not knowing what they're doing sometimes. But, by the same token, in about a year I'm going to be a doctor and I'm going to be unsure of myself and not knowing what I'm doing. Shit! Watching it is strangely comforting and anxiety provoking at the same time. And what's with that Korean character? Why do I hate so much? A strong, attractive, Asian woman who rides a motorcycle - I should be in love with this character! I'm not sure whether the writers want her to be a likeable figure or not. Either way, she's not.

Frat guys

2005-04-03T16:37:00.000-07:00

It was nice to be social again last night. A fellow medical student was having her 26th birthday party at a bowling alley. She goes to a different school than I do. I know her through my friend, Tom. Tom was my former roommate. He's a bright, clever guy who likes to read a lot of comics. He drives a Prius with a bumper sticker that reads: My other car is a Thomas Pynchon novel. He and the medical student went to a state school where they somehow managed to be friends despite all of med school girl's friends being in frats and sororities and Tom being in the film society. Tom decided that, in order to blend in with the state school frat crowd that was going to be there, he and I needed "disguises." He wore an A & F tshirt with a long sleeved shirt underneath and jeans, I wore khaki's and a striped polo with a white long sleeves underneath. He took off his glasses in favor of contacts and, not to be missed, baseball caps were donned by both of us. After about 15 minutes of shouting, making lewd comments and slapping each other on the back, we felt we were ready.
We quickly realized that we were totally out of our depth. The party guests included medschool girl, her voluptuous roommate, about 20 former frat guys and us. Our novice, mini cooper frat guy personas were no match for the mac truck that these guys had cultivated through years of drinking and shameless, loud, obnoxious behavior. We quickly reverted back to our old, albeit costumed, selves. And it was for the best. Medschool girl and her roommate paid way more attention to Tom and I (as ourselves) than to any of the other meat-heads there. It was a pretty good night - even if medschool girl was totally out of my league.

Ethical dilemma theater: Part IV

2005-04-02T09:50:00.000-08:00

I saw a patient yesterday with a pretty significant resting tremor on the right side. His entire right arm moved rhythmically back and forth as he sat still. He could hold this arm still if he concentrated or when using his hand to write. But once his attention was diverted from it, his arm would resume it's rhythmic jerking. The doctor didn't say anything to the patient about it other than, "It worries me." Interestingly, this isn't even what brought the patient into the office. He was just there for a routine check-up and attributed the tremor to drinking too much coffee.
I thought he was a little too young to have Parkinson's but, after the patient had left, Dr. Levin told me "Yep, that's Parkinson's alright. I didn't tell him because it would make it harder for him to get insurance. And besides, we wouldn't want to start treatment yet; no sense in worrying about it now."
Um, er- give full disclosure much?
Whatever. I would've said something but...the life of a medical student is already hectic and exhausting enough without us seeking out new battles for ourselves. I'm learning to roll with it. I think, one day I'll be an attending, and then I'll allow myself the luxury of practicing good ethics.

One last psychiatry rant

2005-03-31T20:52:00.000-08:00

So, I felt the need to get on my soapbox one last time after reading this post over at mudfud. After this, posts will relate to medicine only. I have purged myself.

There will never be such a thing as a biologic marker for depression. Even if it existed, of what use would it be? If I felt fine but had some biological marker that indicated I had depression, should I take medication? Why? What would be the point? Likewise, if someone feels horribly depressed but doesn't have the marker, should we not treat them? Of course not.
I guess you could use it for screening, but what's the point of screening for depression? The point of screening is to treat illness before it becomes symptomatic. But depression, by definition, cannot be asymptomatic. So, why screen for it?
There may be other conditions out there (i.e. hypothyroid) that secondarily cause depression. And there may very well be biological markers to test for these diseases. But for a biological process to cause no other physical symptoms except for those associated with depression? I suppose it's plausible but, I think, highly unlikely.
How do the patients in these studies get their diagnoses anyway? The DSM. Diagnosing psychiatric illness isn't at all like diagnosing hypertension, anemia or diabetes where a simple number gives you the diagnosis. It requires people to make a judgment call, in every case, as to whether the DSM criteria apply. And how often do psychiatrists agree on whether the DSM criteria apply? Depression is one of the most reliable DSM diagnoses and it is only about 80% reliable. Psychiatrists agree on whether or not a given individual is depressed about 80% of the time. And unlike diabetes or hypertension where a diagnosis is either correct or incorrect there is no higher authority to say who made the "right" psychiatric diagnosis. Therefore, since the diagnosis itself is only 80% reliable, any biological marker we found could only be at most 80% reliable.
Ok, let's say that you believe the DSM only approximates these "biological" illness and you believe that with biology and genetics we will finally be able to make the "true" diagnosis. The DSM becomes obsolete. Schizophrenia, for example, is found to be a heterogeneous group of illnesses each with it's own abnormal proteins produced by their own abnormal genes. Schizophrenia is no longer a psychiatric diagnosis but a neurological diagnosis. I once had a professor who said that one day, there will no longer be any psychiatrists but only psychologists and neurologists. I agree. But, while neurology might grab a few, I think psychology is going remain in control of the vast majority of current psychiatric diagnoses.
Soapbx disengaged.

Grand rounds: edition 27

2005-03-30T09:41:00.000-08:00

Grand rounds are up at Over My Med Body. Check out some interesting posts from various medical bloggers.

The Fat Man

2005-03-29T20:45:00.000-08:00

So, I was scheduled to begin medicine today. Little did I know, my psych rotation had been extended one more day only, the setting had been changed to Dr. Levin's outpatient internal medicine clinic.
It was the last patient of the day. I was starting to get into the swing of things, relearning how to use my stethoscope - I basically hadn't touched a patient in 6 weeks except to shake hands. This lady was skinny with long, gray hair looking much younger than her stated age. When I called her from the waiting room she was helping a lady in a wheelchair get her feet propped up properly.
"Someone you know?" I asked.
"No, but she needed help."
She happened to be a nurse, and so was completely aware that our conversation was going to have very little bearing on her treatment but was quite happy to talk to me anyway. And talk. And talk. She described symptoms of chronic fatigue and headache, casually slipping in that she had recently discontinued her antidepressants. She'd also had multiple CAT scans and MRI's, some for neurological symptoms, some for her chronic sinusitis. The longer I talked to her, the more doctors her story introduced me to: neurologists, psychiatrists, gastroenterologists, otolaryngologists, another general practitioner who "didn't take her symptoms seriously." I did my best, but this was all a bit much for me to handle on my first day of medicine. I reigned her in, and did a thorough neurological exam - which she really seemed to appreciate. "I'm so glad you're examaning me. Your exam has reminded me, I noticed that one of my pupils was bigger when I looked in the mirror last week." I added this, newest complaint, to her HPI.
I explained all this to Dr. Levin. He listened patiently and intently before we went to see her. Maybe it was just the luck of the draw but, after having worked with some pretty shady and self-absorbed psychiatrists, I was all set for Dr. Levin to completely brush the patient off, start her on some new antidepressant and tell her (in so many words) not to come back. He did start another antidepressant, but didn't brush her off in the least. He listened to what she had to say, looked at her MRI and answered her questions. During the interview, she expressed fear that he would drop her as a patient after discontinuing her meds. He had no intention of dropping her - unless she wanted to be dropped, which she didn't. It was a good match.
I see now why Dr. Levin's office is so full of gift baskets from all his patients. At the end of the day, he gave me a bag of muffins because there was simply too much food around. Dr. Levin is the character The Fat Man from House of God. He knows his medicine, says what's on his mind and patients absolutely adore him. I'm excited about this preceptorship.

My political persuasion

2005-03-27T22:04:00.000-08:00

Apparently, I'm a liberal. Who knew?

Thanks to orac for posting the link. Please, send me a trackback if you decide to take the quiz yourself!

Dr. Lin threesome

2005-03-27T13:30:00.000-08:00

So, I was checking the url's referring to my site - as us bloggers do - and I found something a little strange. On 3 separate instances and from 3 separate ip addresses, someone searching Google for "Dr. Lin threesome" was referred to my blog. The question who whether my blog has anything to say about "Dr. Lin threesome" aside, why the hell would anybody be searching for "Dr. Lin threesome" in the first place? Who's Dr. Lin? And what does she have to do with threesomes?
Anybody? Anybody? Bueller?

Reverse date rape?

2005-03-25T11:13:00.000-08:00

I'm a horny guy. I'll admit to it. There was an M4 on psych rotation with us - the most voluptuous Indian girl you've ever seen, with an ass that follows behind her like the trailer on a semi. Whenever she turns a corner, her ass remains in plain view. She sat in front of me to take the psychiatry shelf exam today, wearing black pants that failed to contain the entirety of that ripe peach which she rested gingerly upon the chair, exposing almost a full inch of intergluteal cleft as she leaned forward. I finished the exam as quickly as I could and rushed immediately home to masturbate.
The point of telling this story is, I'll match my horniness up against anyone's. But, that being said, I very much resent what seems to be a social expectation of horniness whenever our significant other happens to be in the mood. Skye was in town this weekend. We had some great fun together but, there are occasions during which I am very tired and would rather just sleep. What does one do in the event that one finds oneself being kissed and groped just as rapid eye movements are pleasantly settling in? Does one say "no?" I've said "no" before; usually I'm met with various combinations of sobbing, confusion and anger - depending on who I'm with. At that point, I reluctantly give in. Ok, so it's not really against my will. I am a willing participant. But 'no' should mean 'no.' I should be able to say 'no' without feeling guilty about it.
Here's the problem, the message that men have consistently received from our society is: "You'd better be horny all the time because your girlfriend is only going to be horny some of the time. You wouldn't want to waste an opportunity." Women are used to being pressured for sex and so it's become perfectly culturally acceptable, and even encouraged, for women to say "no." This engenders a culture where, when women do decide they are willing to put out, the expect - even, feel entitled - to have someone out there who will want them and they will feel rejected as all get out if this isn't the case. You see the position we're in? It's not easy to reject someone like that. It's much easier to acquiesce and give them what they want.
My point is that the passive, subtle ways that women have of pressuring men for sex are every bit as coercive as the more overt, forceful ways that men have of pressuring women for sex. And they're both BAD! So don't do it. If you're a guy, the solution is simple - just don't force yourself on anyone. If you're a girl, there's no need to cry if your boyfriend says "no." You're not undesirable. Just wait till morning. Unless you have hair around your nipples or below the navel in which case, it may be that he finds you undesirable.

The Antipsychiatry Movement

2005-03-24T09:06:00.000-08:00

"Only more powerful people can call less powerful people schizophrenic and get away with it safely." Thomas Szasz said this at a conference in 1984. He believed that schizophrenia and depression are not diseases but "social fictions" used by more powerful people to treat less powerful people against their will. He compared the label of 'schizophrenia' to the counting of blacks as 3/5 of a person in the U.S. Constitution - useful to the rest of society, but not useful to black people themselves.
Szasz and other authors, such as R.D. Laing and Peter Breggin, were the subject of a Psychiatry Grand Rounds given at school today entitled The Rise and Fall of the Antipsychiatry Movement. The resident who gave the talk - and most of the faculty members in that room, for that matter - would like to believe that the so-called "Antipsychiatry Movement" has indeed fallen. But he acknowledged that, because treating mental illness is inherently different than treating medical illness, there will always be a certain sector that questions what psychiatrists do. From the little I've learned about Thomas Szasz, I think he makes some excellent points. He believes that psychiatry is ok, as long as it happens between consenting adults. If you want to try medication for your illness or if you think that, as a patient, you would benefit from hospitalization, fine. But, according to him, hospitalizing people against their will is always wrong - preventing suicide in someone is not sufficient justification for taking away their rights and homicidal people should be delt with by the police. Here's a fascinating transcript I found from a 1998 debate on the question of: "Is depression a disease?" Szasz and 5 other psychiatrists participated. I've always agreed with those who say it is not. Depression is a constellation of symptoms with no identifiable cause. This is not to minimize the suffering of depressed people, but to say that it is a mental and spiritual process and not a brain illness or a biochemical disorder.

One of the psychiatrists in the audience of today's Grand Rounds, Dr. Butz, in the course of blasting Peter Breggin and the rest, brought up Ernest Hemingway. Hemingway was a psych patient at Mayo Clinic shortly before his subsequent suicide. Dr. Butz had happened to be in Minnesota at the time and had happened to run into the intern who was following Mr. Hemingway's case. Although, the official story is that Hemingway got between 11 and 15 ECT treatments, Dr. Butz claims to know different. Apparently, they had declined to do ECT on him fearing it would stifle his creativity. To this day, Dr. Butz believes that ECT would have saved Ernest Hemingway's life. What do you guys think? If Michelangelo had been suicidal, would you have cut off his hands in order to keep him from killing himself? I think ECT would have only driven Hemingway to suicide faster.

Mrs. Katz got her ECT after all - treatments began today. She had signed the "consent" form over the weekend. This morning she asked me, "Is there a risk of brain damage with this procedure?" My answer,
"Well, technically, the procedure is brain damage."

Grand rounds: edition 26

2005-03-23T12:34:00.000-08:00

Sorry for the delay in posting. Skye was in town this weekend so I was a little, um, preoccupied. This week's grand rounds can be found over at The Well-Timed Period. Submit posts for next week to Graham at Over My Med Body. Today was my last day on psych rotation. I promise to post a good wrap-up tonight.

Ethical Dilemma Theater: Part III - Informed consent? I've got your informed consent right here!

2005-03-18T15:10:00.000-08:00

It was time to present my new patient this morning. I had called Mrs. Katz on the phone last night in order to get the rest of her history. She was a 68 year old lady with an 8 year history of depression. She had been managed as an outpatient up until this point, but her condition had acutely worsened when her regular psychiatrist decided to stop her TCA (tricyclic antidepressant) about 7 months ago. She had tried several medications in the interim, but nothing had helped. Finally, her regular psychiatrist decided he'd had enough and referred her to our hospital for ECT (shock therapy). I asked Dr. Beck about restarting her TCA. His response was, "She won't get better because she'll complain about the side-affects." Well, ok sure, that's possible. This lady was pretty ill. And if Dr. Beck - the attending psychiatrist - thinks that ECT has a better chance of helping her, why not give it a try? - as long as she's amenable to it.
The problem was, she wasn't amenable to it. She wouldn't sign the consent form. But Dr. Beck wasn't about to let a pesky detail like "informed consent" get in the way of pursuing what he thought was the best treatment option. In a flash, Dr. Beck had the patient's daughter on the phone and for a solid 30 minutes Dr. Beck, the psych resident, the social worker and the patient's daughter did their darnedest to harangue Mrs. Katz into signing the consent form. Each member of the team had his own strategy. The social worker tried to convince her that it was in her best interests and that she'd feel better. The psych resident tried to explain why ECT was best option in terms of a risk:benefit ratio. And best of all, Dr. Beck's strategy was to put on his most excellent used car salesman face, shove a fancy pen into Mrs. Katz hand and say, "Come on, just sign it. See?" tapping the dotted line, "Just sign right there. We just need a signature and then we can start getting you better." I thought I was going to be physically sick.
She didn't end up signing, but Dr. Beck put her on the schedule for Monday anyway. He's hoping the daughter will be able to convince her mother to sign when she visits in person this weekend. I left a patient handout on ECT along with a couple of articles on the subject with Mrs. Katz, hoping it will help guide her and her daughter in making an informed choice.
Personally, I think it would be worth another trial of her TCA. What's the worst that can happen? It doesn't work, in which case ECT is back on the table. Suicide is always a concern because TCA's are fatal in overdose. But she has been asked multiple, multiple times about suicide ideation and has consistently denied it. She also has no history of suicidal behavior and no previous psych hospitalizations. In the end, whatever treatment option we pursue doesn't really matter as long as it's what the patient wants. I don't think giving in to high pressure salesmanship really counts as informed consent. It will have to come from her.

Work from home

2005-03-17T18:23:00.000-08:00

We released our hostage today. The patient had signed his 5 day notice 1 week (5 business days) prior to my first day on service. That meant we had to either release him, or go to court to justify keeping him. The court date was set for 3 days later and when the court date came, as has become standard procedure, they issued a continuance (postponed making a ruling) for 1 week. That one week was up today - 17 days after the patient had originally requested to be discharged. And he hadn't gotten any better. In fact, he had gotten worse. His delusions were more elaborate and his blood sugars were running in the 400's. But, in order to keep him, we would've had to go to court yet again. The 3 med students looked on this morning as the nurse, social worker and psychiatrist all looked at each other saying, "I think he's better, don't you?"
"Oh, yes. Much less agitated than when he came in."
"Yep, definitely calmer. See, he's not clenching his fists anymore-"
"This is probably his baseline anyway."
They called the patient in and said, "Congratulations! You're free to go."
I'll miss pt J.J., always asking for his diet 7-up. He asked so often that the resident finally wrote an order: 1 diet 7-up qShift. If I'm ever in the hospital, I'm going to ask the resident to write an order for 1 foot massage q6hrs PRN.
Note to any mentally ill people who might be reading this: if you're not suicidal or homicidal, think twice before signing yourself into a hospital - you may be there longer than you had planned.

There was a new admission last night. I went to do the history after getting back from lecture but she was tired and in no mood to be talked to. But I didn't have any other clinical responsibilities today. And I didn't fancy waiting around until my patient had had her nap. So I went home and called her this evening. It was great - I just finished writing it up. Makes me wonder why I ever need to go into the hospital at all!

Sex toys: the silent killer

2005-03-16T18:50:00.000-08:00

You'll never see any two people with more discrepant personalities than Ryne and Ned. They're both in my M3 class and on pediatrics rotation now. Ryne is 30, skinny, dark hair, glasses and extremely even keeled. To even contract his facial muscles into the form of an expression would be considered an emotional outburst for him. Ned, on the other hand, is 24 and somehow managed to work his way into medical school despite his, apparently undiagnosed, ADHD. I think it was pure Taoism that got him in.
The subject of today's lecture was pediatric AIDS. When the subject of transmission came up, vertical (mother to fetus) transmission was obviously at the forefront. But we explored the other modes as well: unprotected sex, IV drug use, and blood transfusions. Naively believing we had exhausted all the possibilities, we were rudely awakened from our delusion as Ned asked, "What about vibrators? You know, like, with lesbians. If one has AIDS and she shares her vibrator with her partner...can it be transmitted that way?"
The class broke into an uneasy laughter. Our course director chuckled and said, "Yes, I suppose that's a possibility too."
But the class really exploded when Ryne raised his hand and, in all seriousness asked, "Is that specific to vibrators or does it extend to other toys as well?"

Moral: Write letters to your respective congressman - the government needs to start providing clean sex toys to all lesbians in order to help curb the spread of AIDS. Republicans need to realize that this moralistic policy of denying lesbian access to free sex toys is a public health disaster. Pretty soon it won't be just a lesbian problem anymore, but bisexual females will spread the disease to straight males and the AIDS epidemic will spread out of control in this country.

Visitor

2005-03-15T20:19:00.000-08:00

Skye is coming to visit this weekend. I'm...excited. I guess. I don't know. I really do want to see her. Although, if she knew what was good for her, she'd probably forget about me and start seeing someone else. I don't understand why we can't both just be adults with regard to our relationship. I won't ask what she does while she's in California, she won't ask about who I'm doing over here and then, when one of us visits the other, we can play like we're in a real relationship. Is that so hard? But no, she has to define our relationship. And there are all these rules like: we can't have sex unless we're going to be exclusive with one another. It's all so immature.
I think life would be a lot easier if I were gay.
Which, I AM NOT.
Not that there's anything wrong with that.

Grand rounds: edition 25

2005-03-14T23:32:00.000-08:00

Orac has done a nifty job with Grand Rounds this week. Check it out here.

Public airwaves

2005-03-14T19:52:00.000-08:00

I'm beginning to think I have a problem. The hours I spend each evening - motionless, pupils dilated, neurons firing like mad - I've lost 85% of my productivity. Sometimes I even indulge well into the late-night hours. I'm addicted to PBS and NPR. It all starts with Car Talk followed by The What Do You Know Quiz and This American Life on Saturday morning and progresses to Prarie Home Companion and Selected Shorts on Saturday evening. Sunday morning is reserved for brunch and by the time I part ways with the rest of "The Intelligencia," we're already into Wait, Wait, Don't Tell Me, Le Show with Harry Shearer, Shadenfreude the mental massaging of Joe Frank and, of course, Ken Nordine's Word Jazz.
My weekday routine is also a sad story of servitude to the airwaves. I come home from the hospital, jog my frustrations away and plop down in front of The News Hour and, inevitably, PBS has me hooked with some interesting special event or documentary. Tonight it's a concert program featuring stars from the 80's. I'm not remotely gay but GOD, Freddie Mercury is HOT!
Are there any support groups out there for this kind of thing? Somewhere where I could go - I would stand up and say, "Hi, my name is T.J. And I'm addicted to public television and radio."
"Hi T.J.," everyone would say in unison.
They could give me a sponsor named Bill. The group leader would say to me, "Next time you get an urge to watch PBS or listen to NPR, I want you to call Bill instead."

I'm not really sure where I was going with this post. The point is, I need to tear myself away from Mick Jagger and Tina Turner and do some reading.

Ethical dilemma theater: Part II

2005-03-13T16:42:00.000-08:00

Dr. Solomon is a big name in the field of psychoanalysis at our institution. I walked into 8am "Dr. Solomon rounds" on Friday morning and sat next to an older, white-haired gentleman wearing a tan sportcoat and conservative tie. He immediately began asking me questions - "Are a you a student?" "What rotations have you done so far?" "Where are you from?" "What do your parents do for a living?" I answered his questions for awhile and, at about 8:15, he got up and walked to the front of the room to begin rounds. I had been talking to Dr. Solomon.
What happens at "Dr. Solomon rounds" is this: a psychiatry resident presents a case and Dr. Solomon comments on it from a psychoanalytic perspective. Today's case involved a Hispanic lady with complaints of depression who had one story of abuse after another to tell her therapist. The resident who presented her had so far done about 3 months worth of therapy with this woman.
I learned on Friday that countertransference is an important part of psychoanalysis. Analysts look at how their interaction with the patient makes them feel and this is supposed to reveal something about what is going on with the patient. Dr. Solomon listened patiently for about an hour before asking the psych resident, "Yes, but how did all of this make you feel?"
The resident admitted that she had been sympathetic at first, but had subsequently become annoyed with all of her sob stories. What is the proper response to this feeling of annoyance? According to Dr. Solomon, there is a school of psychiatry out there which advocates that the therapist be totally forthcoming and honest with his feelings thereby making himself more emotionally accessible to the patient. "If you're annoyed, you should tell the patient you're annoyed. If your patient is a model and asks you 'Do you find me attractive?' you tell them 'Yes, I find you attractive. I get an erection just thinking about you.'" Is this level of openness acceptable? What should proper doctor-patient boundaries be? If a patient asks you to go to a basketball game, is it alright to accept? Some psychiatrists have lunch with their anorexic patients believing that it's therapeutic. One could argue that, if the patient doesn't have many friends, attending the basketball game together will offer therapeutic benefit by providing him with emotionally validating experience. What if having sex with your patient is somehow therapeutic for them? It's not inconceivable. Sex is often therapeutic. (I think this question will be explored on an upcoming episode of House - I can't wait!).
I haven't really formulated my own opinions about this issue yet. I'd love to hear some opinions while my mind is still pretty clay-like.

Mindless fun

2005-03-11T22:15:00.000-08:00

Ok, Ethical dilemma theater: Part II is going to have to wait. In the meantime, vicarously live out your sadistic tendencies though some great pencilmation.

I can't take credit for the following, but neither did the original author. So, here it is. Enjoy! Back with an original post tomorrow - promise!

DICTIONARY FOR WOMEN'S PERSONAL ADS:
40-ish...........................49
Adventurous..................Slept with everyone
Athletic..........................No tits
Average looking.............Ugly
Beautiful.......................Pathological liar
Contagious Smile..........Does a lot of pills
Emotionally Secure.......On medication
Feminist........................Fat
Free spirit......................Junkie
Friendship first..............Former slut
Fun.................................Annoying
New-Age.......................Body hair in the wrong places
Old-fashioned................No BJs
Open-minded.................Desperate
Outgoing.......................Loud and Embarrassing
Passionate.....................Sloppy drunk
Professional....................Bitch
Voluptuous...................Very Fat
Large frame....................Hugely Fat
Wants Soul mate............Stalker

WOMEN'S ENGLISH:
1. Yes = No
2. No = Yes
3. Maybe = No
4. We need = I want..
5. I am sorry = you'll be sorry
6 We need to talk = You're in trouble
7. Sure, go ahead = You better not
8. Do what you want = You will pay for this later
9. I am not upset = Of course I am upset, you moron!
10. You're certainly attentive tonight = Is sex all you ever think about?

MEN'S ENGLISH:
1. I am hungry = I am hungry
2. I am sleepy = I am sleepy
3. I am tired = I am tired
4. Nice dress = Nice cleavage!
5. I love you = Let's have sex now
6. I am bored = Do you want to have sex?
7. May I have this dance? = I'd like to have sex with you
8. Can I call you sometime? = I'd like to have sex with you
9. Do you want to go to a movie? = I'd like to have sex with you
10. Can I take you out to dinner? = I'd like to have sex with you
11. I don't think those shoes go with that outfit = I'm gay

No voices this time

2005-03-11T17:04:00.000-08:00

I had lunch is one of my classmates today. She's a petite, Korean girl - probably weighs about 85lbs, dress size '0.' I had the small chef salad and a skim milk. She had a cheeseburger and a Krispie Kreme doughnut. Life just isn't fair.

Part II of ethical dilemma theater to be posted tonight...
Plus, a bit of good news. My paper on medical futility as a justification for DNR orders is going to get published by a student publication out of California. Yes! Few people know this about me but, while I have the more immediate goal of becoming a doctor, I'd eventually like to become editor-in-chief of the American Journal of Bioethics or some similar publication. I then plan to use that position as a springboard, launching myself into a series of bloodless conflicts after which I find myself in a situation where I happen to be ruler of the free world. It's all part of the 75 year plan which, so far, appears to be right on schedule :)

Ethical dilemma theater: Part I

2005-03-10T13:42:00.000-08:00

The following is a real ethical dilemma involving a real patient at our hospital. The details have been changed to protect the innocent. And the guilty.

Dr. Bradshaw holds rounds in a small conference room on the inpatient psych unit. There are 4 medical students on his service, a resident and a social worker who takes care of things like discharge planning, court hearings, setting patients up with social services - in other words, 90% of all the useful things that happen on the psych ward. Lynne was the medical student who had been on call the previous night and she had admitted a new patient to Dr. Bradshaw's service. She began presenting the patient to the team, "F.P. is a 55 year old male with a history of bipolar disorder and alcohol abuse..." This is the part where most of the other medical students fall asleep before arousing once again to present our own respective patients. But something in Lynne's presentation caught our attention. She went on, "Patient denies anhedonia and feelings of worthlessness or hopelessness. He says he often feels guilty because he killed 2 people in 1978, no suicide ideation or homicide ideation..." The rest of us looked at each other. Had we heard correctly? Had I fallen asleep briefly and had a hypnogogic auditory hallucination? When she was done, Dr. Bradshaw asked,
"What would you like to do?"
Lynne's answer came out as casually as if she had been ordering a turkey sandwich at the deli, "Restart his mood stabilizer at it's previous dose, give 100mg of trazodone to help him sleep at night, put him in touch with social services so he can start collecting disability and call the police."
This prompted a very long and emotional discussion of patient confidentiality vs. duty to protect, vs. justice. No real consensus was achieved.
Luckily for us, the law is pretty clear. We're never allowed to violate patient confidentiality except in some very specific circumstances (i.e. suspicion of child abuse, elder abuse, the person poses an immediate danger to someone, the reporting of certain infectious diseases and in some states, parents must be notified if a minor is having an abortion). This patient hadn't made any specific threat. What would you do?
Here's what we did - we called Legal Affairs (read: copped out). They were out to lunch. We're still waiting for them to return our call.

Shock therapy

2005-03-09T17:12:00.000-08:00

You thought maybe this went out of style during the McCarthy era? You thought that this is kind of stuff that can only happen in movies like, A Beautiful Mind or One Flew Over the Cuckoo's Nest? You'd be wrong.
Medical students at my school are required to attend at least one session of ECT (electroconvulsive therapy) in order to pass their psychiatry rotation. ECT is mainly used today to treat intractable depression. It's done a little more "humanely" that it once was, but the principle is still the same. The patient is sedated using something like thiopental or ketamine, a tourniquet is placed on an arm or a leg and succinylcholine (a paralyzing muscle relaxant) is given. The tourniquet is to keep the succinylcholine from reaching that limb so we can verify that the patient is having a seizure. The succinylcholine is mostly for our benefit - so we don't have to watch the patient flopping around. Two electrodes are placed - one on each temple - and a charge is administered. Somehow, out of the 3 medical students observing, I was the one that had the dubious pleasure of holding one electrode while the shock was given. The patient's facial muscles tensed violently for about a second, the current was stopped and the prototypical rhythmic jerking of a myoclonic seizure was seen in the tourniqueted left foot. This lasted about 25 seconds.
Alright, I don't care what the literature says, the idea that inducing a seizure can somehow be therapeutic is just plain crazy to me. If there were studies showing that kicking someone in the balls repeatedly improved their depression, would you do it? How many times would you do it? If the patient didn't improve after 10 kicks to the groin, would give him another 10 kicks? Another 100? It's insane.
So, that's my biased, uninformed opinion. I'm going to read some articles on the subject now. Maybe it will change my mind completely and I will recant everything I said in this post. But, I doubt it.

Grand rounds: edition 24

2005-03-08T06:25:00.000-08:00

Check out this week's Grand Rounds. Thanks to Hospice Guy for hosting. My own contribution is here. Submissions for next week should be sent to Orac at Respectful Insolence.

Welcome to the psych ward - you can check out any time you like, but you can never leave

2005-03-07T21:06:00.000-08:00

My new resident on the in-patient psych unit is tall and lanky, wears a scruffy beard (the goatee portion is one length and the rest is another) and wears his fiery red hair in a long pony-tail. I imagine him having studied something like philosophy as an undergrad. A little eccentric but, if you saw him walking down the street, you probably wouldn't look twice - certainly not in an urban setting like ours. Seems like a perfectly acceptable style for a psychiatry resident, but does anyone know any neurosurgeons who present thusly? Anyway, I like him. He seems like a really smart guy.
At rounds this morning, his attending decided that one of the patients on our service - a 65 year old man with bipolar disorder and an acute exacerbation of his manic symptoms - was not fit to leave the hospital. The man had signed himself into the hospital voluntarily when his caseworker found he was having delusions of having won the lottery and making plans to rent a hall for a party to which he was going to invite 75 people. He was otherwise very much intact - having some trouble sleeping but no signs of depression, suicidality, homocidality or other psychotic symptoms. His biggest complaint was being upset at not being able to leave.
Here is a disturbing fact I learned today: In our state, if you're hospitalized in a psychiatric ward and decide you want to leave, the hospital can keep you for up to 5 days before being obligated to come up with a justification for keeping you. There are only 3 such justifications - 1. you are mentally ill and a danger to yourself or others, 2. you are mentally retarded and a danger to yourself or others, 3. you would be unable provide for your own basic needs if discharged. This means that (as happened in this case) some people who come into the hospital voluntarily will be forced to stay involuntarily! WTF?! If the person was competent to sign themselves in and their condition hasn't deteriorated since coming admission how is it that they are not also competent to sign themselves out?
Well, apparently this patient wasn't competent to sign himself out based on criterion #1? #3? The resident totally disagreed with this assessment and I think he was right. He racked his brain for awhile, thinking about what he was going to write on the certification form. The patient wasn't agitated. He hadn't made any specific threats except for the threat to sue for $5 million for every day that he couldn't leave. The resident wrote down some B.S. about the delusions in the chart. Ethics can be so pesky sometimes.

Psychotic symptoms due to reduced glucose intake

2005-03-05T23:56:00.000-08:00

I think I’ve got the upper hand in the ongoing calorie war now. I came home to my parents’ house for dinner tonight. We ordered Chinese food. When my mom, my dad and I order Chinese food, we always get 2 orders of egg rolls. There are 2 egg rolls in an order, making for a total of 4 egg rolls. My mom eats one, my dad eats one and I eat one. Inevitably, I’m offered the left-over egg roll, and inevitably I can’t resist it. This has been going on for years.
My dinner tonight would consist of the following:

½ of a small order of curried chicken with some white rice
4-5 spoonfuls of vegetarian fried rice
1 egg roll
12 ounces of carbonated water (I love that stuff)

Don’t think I wasn’t tempted by that last egg roll. It stared at me from the communal serving dish. I stared back at it. It begged me to eat it, tempting me with its crispy, fried outer shell. It said, “Take me, or someone else will take me first!” I ignored it. “Don’t be a fool,” it refused to be ignored. “Eat me now! You may not get another opportunity to eat Chinese for weeks!”
“No!” I said. “Stop tormenting me, damnit! You can’t control me, so just shut up.”
My mother put down her fork which had frozen midway between plate and mouth. “Who were you talking to?” Whoops. My mouth, tongue and larynx had just conspired to form words that I had meant to say only in my head.
“You heard me. I said, shut up and stop trying to control my life.” I hadn’t actually been listening to what she had been talking about while I had was having my private diatribe with the egg roll, but odds were at least 1:1 that it was something critical about the way I run my life.
“I’m sorry.” She looked down at her plate. “I know you are capable of making your own decisions. I won’t say anything more about it.
Phew – that was a close one! I wiped my mouth, wiped my brow and excused myself with both appearances and will power in tact.

A 20 year old man came to our clinic the other day. The referral form from the screening clinic downstairs said, “Bipolar disorder with psychotic features and a history of ADHD since childhood.” He had been given a prescription for an antipsychotic. His answers to my questions about depressive symptoms and manic symptoms raised suspicions in me as to whether his diagnosis of bipolar disorder had been incorrect. I went on to try and flush out these “psychotic features.”
Q: Do you ever see things that aren’t there?
Ans: No.
Q: Do you ever see things that other people don’t see?
Ans: Yes, I see things that other people don’t see. But those things are actually there.
Q: What kinds of things do you see?
Ans: Ghosts. Spirits. Some of them are people I recognize, others I don’t know.
Q: Do you ever hear voices?
Ans: Yes.
Q: What kind of voices?
Ans: Voices of people I knew when I was 5.
I pursued this further. It turns out he was involved in this awful childhood experience at that age where he and 6 friends were kidnapped and held in a basement for 2 days where they were given drugs and were sexually abused. 4 of them were murdered but he and 2 others escaped. It’s their voices that he hears, voices of the ones who died. They ask how he’s doing. He talks back to them sometimes, as long as no one’s around. I asked if he’d ever talked about this experience with a doctor before. He hadn’t! I couldn’t believe it. Having been treated for psychiatric illnesses since childhood you’d think it would have come up at some point. The upshot is, Dr. Wilson was also unconvinced by the previous diagnosis of bipolar and we lowered the dose of mood stabilizer that he was on. The hallucinations? My guess is that he has subclinical PTSD. He believes that spirits really do appear to him. In the absence of any other psychotic symptoms, who are we to say different? Maybe spirits really do appear to him. Either way, I don’t think my own personal beliefs about the spiritual realm (or lack thereof) have any place in determining what a patient’s treatment should be. If a psychiatrist is an atheist, should he give his Christian patients Haldol to make their belief in God go away? Of course, what if God is telling the patient to hurt people, or to throw herself in front of traffic? Luckily, we didn’t have to worry about those kinds of things with this patient. His “hallucinations” were entirely undistressing to him. I think not “treating” them was the right thing to do. We discontinued the antipsychotic.

As for the egg roll, I think my brain just needs time to adapt to the new diet. Before too long, those neurons will be metabolizing ketones like nobody’s business.

Diagnosis: evil

2005-03-03T19:26:00.000-08:00

I always love the lecture on personality disorders. It's my favorite part of psychiatry. Also scary, as we identify traits in ourselves that are associated with various pathological personality types. I don't meet the DSM criteria for having a personality disorder. But, if I did, I'd probably be a Cluster C - avoidant, dependent, obsessive/compulsive. Here's what an online quiz had to say about it:

Disorder	Rating
Paranoid:	Low
Schizoid:	Low
Schizotypal:	Low
Antisocial:	Low
Borderline:	Low
Histrionic:	Moderate
Narcissistic:	Moderate
Avoidant:	Moderate
Dependent:	Low
Obsessive-Compulsive:	Low
-- Personality Disorder Test - Take It! --

The discussion of personality disorders, particularly antisocial, reminded me of an article I read a few weeks ago (abstract here) about whether there are people who transcend our diagnostic acuity and are just plain evil. I've satisfied myself that the question of whether someone is evil is between that person and god and that there's really nothing else for the rest of us to say about it. It has nothing to do with the heinousness of the act, but everything to do with the individual's culture, his own moral beliefs and his psychological state.

I kind of forgot where I was going with this post. The only other relevant thing I can think of at the moment is: don't ever date someone who's borderline. Or, if you're female, stay away from those antisocial types.

Please welcome...God

2005-03-02T21:33:00.000-08:00

Please welcome, the first ever guest writer at Blog of the Anonymous Clerk, God

I hope you're not too down today. I realize your visit to the clinic didn't go quite as you had hoped. Try to realize that they mean well. But, like you and like everyone, they are imperfect human beings. They want to help, but sometimes they let their own agenda get in the way. But don't tell them about our conversations, whatever you do! If you do, they'll think you're crazy. And you're not crazy. You're enlightened. They haven't seen the light and until they become Born Again Believers like you, they won't understand. Putting those dark days behind you was the right thing to do. Since you've found me, there's no need to speak of those days anymore. Talking about this past gives life to what should not be remembered, let alone spoken of. One day, they will believe as you do and they will understand. I will help you through these days. We will talk and I will help you cope. These people can't help you now. If you tell them, they will only think you are crazy and they won't help you. They'll hurt you like the others did. But that young man in the short white coat really does want to do his best for you. Try not to hold it against him - he just hasn't seen the true reality yet. You have. You are saved.

Inspired by this post at intueri.org.

A short trip to Hypoglycemia

2005-03-01T22:49:00.000-08:00

When you enter our medical school as a first year student, you are paired with an upperclassman who is designated your "big sib." My little sib happens to live in the apartment directly above me and she is cute! Today was the first time I had an excuse to knock on her door. It was our annual "big sib dinner," and I thought it would be nice for us to walk over there together. We had Thai food. I gave some big brotherly advice. Midway through the dinner, my own big sib showed up. She had just come from the OR - she was on plastics and they were replacing a patient's jaw with his fibula. So there we were. 3 generations of sibs. Pretty wild stuff.
It was my turn to volunteer at the homeless shelter tonight. This is the part where upperclassman teach the underclassman how to do a focused history and physical and how to write a good note. I hope I wasn't completely useless to my underclassman tonight. My mind just wasn't there. As you can probably tell from the quality of this post, my mind really isn't here either. It's because I'm on a diet now - restricting my caloric intake. Not enough glucose to the brain.

Major depression secondary to prozac use

2005-02-28T18:45:00.000-08:00

So, I had just seen one of Dr. Feinhauer's patients. I come back in the conference room to present to her and she's gabbing with the students about this or that neighborhood and how great the rent is and what a great view this or that high rise has. I wait patiently for a good 4-6 minutes before gently interrupting, "Dr. Feinhauer, would you li-"
"What! What do you want?" My colleague's collective eyes widened. Some had to cover their mouths to keep from laughing and not because the situation was funny - quite the contrary - the laughter they suppressed was the same laughter we suppress when we see an umpire get hit in the crotch with a baseball. Sometimes, you just can't help yourself.
"I have one of your patients here, she's a-"
Again she cut me off, "What's wrong? What do you want?"
At this point, I declared a failure any further endeavor to make this particular patient interaction into a learning experience. I handed her an already filled out prescription and asked her to sign. She glanced at the treatment plan I had outlined; (I just kept the patient on the same drugs at the same doses she was on before) she signed at the bottom and went back to talking about the hottest urban real estate.
Dr. Feinhauer is something else, for sure. If I, or anyone else, takes too long with a patient or, god forbid, actually take the time to look at the patient's medical chart we are sternly chastised. "Go, go see them. Do not write a whole page. Maximum 1/2 page. Are they stable? Good. You write the prescription and see the next one."
Nimesh, the fourth year student came into the conference room today asking her, "What should I do about this patient who is on the phone? I've asked her to step into the office multiple times."
Dr. Feinhauer spun around in her chair. "My patient?" The student nodded and she was out of her chair and in the hallway as quick as if someone had just set off a firecracker under her butt. The situation was made more comical by the fact that this patient was Spanish speaking. Dr. Feinhauer wasn't willing to wait for an interpreter to translate her vocal bitch-slaps. She ended up passing her off to someone else.

It seems that almost every patient I meet in psychiatry has an interesting story. I wish I could tell them all. Here are a few - real quick-a-like:

1. 38 y.o. male with some serious drug seeking behavior. Nimesh told me the story of how he had seen this patient the week prior, how the other female psychiatrist had accused the patient of being drug-seeking and demanded he get a tox screen, and how he had subsequently stormed out. The patient had apparently come around to the notion of a drug screen (or felt that he'd had enough time to get them out of his system) and come back for another appointment, this time with Dr. Wilson - an excellent move on his part. Nimesh wouldn't see him because he was afraid the patient would get mad and violent; I bit the bullet. He seemed to like me.
Upon getting the story from me, Dr. Wilson said the best thing I've heard a psychiatrist say so far, "Let's see if we cahn develop a good rapport wit heem." Dr. Wilson was great. He was understanding but firm, gently suggesting other options and when the patient refused, he went ahead and prescribed the addictive benzodiazepines. I'm not sure I agreed with his decision, but it's nice to see a psychiatrist treat his patients like human beings.

2. 39 year-old Hispanic man with no psychological problomes (aside from some possible mental retardation) who was referred to our clinic because he cried once during his neurology visit. It's nice to be able to send someone home without any drugs once in awhile:)

3. I presented a 32 year-old male who had major depressive disorder with psychotic symptoms to the other female psychiatrist, Dr. Heiken. While Dr. Feinhauer is a bitch to most of her patients (and most of her medical students) Dr. Heiken seems to be a little dim. I asked her why this patient was on depakote since he had no evidence of bipolar disorder and was already on another antidepressant as well as an antipsychotic. She told me that patients on depakote need their liver function tested every so often. I asked her again why the patient was on depakote and she told me that depakote is often used for patients with bipolar disorder. I asked her a third time why the patient was on depakote and finally the truth emerged - "The patient came to us on depakote." I knew it would be fruitless to try and have a discussion with her about getting the patient off depakote, so I just left it at that.

4. A 53 year old female with major depression. Turns out her family doc had prescribed prozac to help her with her menopausal symptoms. She got depressed after having taken prozac for a few months. I very nearly wrote in her chart, "Patient has major depression secondary to antidepressant use."

5. Another 54 year old African American lady with severe depression and panic disorder. Here is one of many examples of why I'm not a doctor yet. I asked her about alcohol use. She said she drinks about a pint a day but a lot more on her "dark days." I assumed she meant a pint of beer. When the psychiatrist, Dr. Patel saw her, he asked "A pint of what?" Brandy! Holy cow. Even Dr. Patel raised his eyebrows, "That's a lot of alcohol." Dr. Patel mentioned A.A. but didn't push too hard because he didn't think she was functional enough to participate. I wish he had pushed harder. I felt it really had the best chance of helping her.

Min came over tonight. Before she left she said, "Can I get a T.J. hug?" I hugged her, then I picked her up and put her in my closet. It was very typical of our behavior when we were together. I get the biggest kick out of her. Min's mouth never stops. If she's not talking directly to me, she's still talking. And whenever I would do things like pin her to the ground, or put her in my closet or put her hand in my mouth, she would acknowledge that something weird was happening to her but she typically wouldn't attribute it to me. If I had her pinned down or in a bear-hug, for example, she might say, "I'm trapped" instead of "Let me go!" I still love her; there's not question about it. I think she loves me too. Ridiculous, right?
It was the first time I had hugged her since we broke up.

Everything's alright, yes everything's fine

2005-02-24T13:42:00.000-08:00

I love it when I see notes like:
"Everything's fine.
No active Sx's."
or
"Patient ok.
Mother passed away."
These are Dr. Prakash's notes. I saw the patient today. Indeed she was "ok." He refilled her prescription and told her to come back in 6 months.

Dr. Williams cracked me up today. I saw one of his depressed patients - 42 year old female. She was complaining of a lot of irritability, anger and problems relating to people. I asked her about this and she said it was a life-long problem of feeling like she was a target for people or like she didn't fit in. Before I could even tell Dr. Wilson - the Nigerian psychiatrist at the County Hospital - that I was thinking about Axis II disorders, he told me "She ees nut gettin enough sex."
"Really?" I was preparing myself for something really amazing here as Dr. Wilson had just diagnosed 'irritability due not getting any' without having either seen the patient or having been told anything about her sexual activity. "How do you know? I didn't ask about her sex life."
"She as been aving proh-blems with ha marriage," Dr. Wilson said as he perused an old progress note. "She was tinking about leavin ha husbahnd. I tink she is not gettin enough sex." He went on to talk about how you can usually tell with women. They start looking a bit rough and as soon as they start dating someone they look better, they dress better, they are more relaxed - because they are having sex. "Sometimes you cahn hactually tell when a woman has had sex the night before."
He's certainly on to something, although I don't entirely agree with his analysis. I think most women are smarter than that. They don't just wait around for some guy to start fucking them before they start feeling like their existence is validated. If a woman's not getting any, she does something about it - new hair style, weight loss, make-up, etc. and gives the men out there some subtle signals to let them know who she might be willing to sleep with them and...'voila!' It's not rocket science.

But what do I know? Women, please feel free to weigh in on the discussion and set Dr. Wilson and I straight.

The right meds vs the right places for needles

2005-02-23T18:33:00.000-08:00

Well, I don't think there's going to be much reason for me to watch American Idol anymore; the only Asian one just got kicked off. I guess I might continue to root for Constantine. I love his style. I think what makes him so appealing (and the men so much more appealing in general) is that he doesn't need this show. He's just there to have fun. If they pick him, great - if not, he'll thank them for having him on their little program and go back to living his life as a rock star.

"Pt. volatile.
Needs more meds."
That was the entire progress note for one of the patients I saw today - one of Dr. Prakash's. Dr. Proakash is a round jolly Indian psychiatrist who is known for falling asleep during patient interviews and student lectures. He's the director of the students doing the psych clerkship at the County Hospital. The patient was a 52 year-old Hispanic lady being treated for depression. I interviewed her - learned she was hearing voices telling her to throw herself in front of traffic and having paranoid delusions. She had been skipping her therapy appointments because she was too afraid to go outside. In fact, she only ever left the house to keep her appointments with Dr. Prakash! Midway through the interview she stood up. I didn't think she was going to leave, but I guess she felt more comfortable knowing she could get to the door easily. I asked her name one more time to make sure I had the right patient - NONE of these symptoms were in her chart. I gave the story to Dr. Prakash and he completely revamped her medications without asking her a single question! He relied 100% what I found in my interview. I was flattered, but I would've felt a little better if someone with more experience had confirmed my assessment.

Later I saw a black man complaining of panic attacks. A case like his is what med students love. He was upbeat, articulate, able to clearly and thoroughly explain his symptoms. He had classic panic disorder with agorophobia - classic. He had the heart palpitations, sweating, dizziness, feeling like he was going to die, a fear of driving on the expressway or certain social situations would bring this on and he avoided these things because of a fear that it would happen again. He'd been to the ER for the cardiac work-up. It was almost as if he had reviewed the DSM-IV criteria before coming in. His previous psychiatrist had him on Ritalin and Klonopin. Klonopin I understood, but Ritalin? Ritalin is a stimulant - not usually what you give to someone who's having panic attacks.
My heart sank when I realized nobody else was available and I was going to have to present the case to Dr. Feinhauer. She made a face when I told her the patient was on Ritalin from his previous psychiatrist.
"Who put him on that?"
"Dr. Flubbits," I had asked him who his other doctor was.
"I know this doctor," Feinhauer replied, "she was my resident. If he already has a psychiatrist, why is he here."
"For a second opinion," I told her. "He's hoping maybe there's another medication that will help more than what he is on now."
"Second opinion! We don do second opinions. We are up to our ears in 1st opinions! We change his medications and send him back to Dr. Flubbits."
For whatever reason, though, I think Dr. Feinhauer really liked this patient. She asked him to describe his symptoms again, for my benefit, when she realized what a classic case this was. She switched the Klonopin to Xanax and put him on an SSRI telling him to stop the Ritalin entirely. Rather than sending him back to Dr. Flubbits, she took him on herself saying he could only go back to Dr. Flubbits for therapy. "Jou cannot have 2 psychiatrists."
I'll never get to see this patient again. I hope he does well.

Dr. Silverstein is another psychiatrist at the County Hospital. He must be what they call an orthodox Jew - wears a Yamacha (sp?) always wears black and sports a big, curly beard. Just before I left at the end of the day, he mentioned that he was going to an acupuncturist for pain associated with pericarditis. Apparently, she works right there in the hospital. He described her to me.
"She's Asian. Did her undergrad here and her M.D. in Asia, speaks Chinese. She's just energetic and bubbly and attractive."
And as I'm listening to him talk, I'm thinking 'Hmmm, my knee is a little sore. And stiff too - I think my knee is sore and stiff.' On the walk home it became even more apparent. It was my right knee (or was it the left?) but there was definitely a little twinge of something when my foot hit the pavement. It could be nothing. But I think I should get it checked out...just to make sure.

PalmaSutra

2005-02-21T21:55:00.000-08:00

This is a fun little piece of software I just found for my Palm Pilot. Here's one of the 60 sexual positions it describes picked at random:

The Reed
Exciting and stimulating, this position allows deep and intense penetration by the man, who completely controls the movements. The woman is propped up on her back and loins, and places the vagina at an angle enabling good penetration. She then stays relatively passive, but the penetration is very lively because the contact of the two sexes is very tight. Few caresses are possible, but the man can sense his partner's excitement and the effects that she feels.

Alright, so it's not as crucial as my Differential Diagnosis program or my Mosby's Drug Consult program. But who knows, it could come in handy :)

Crazy patients, eh?

2005-02-19T21:01:00.000-08:00

Please don't page me, please don't page me, please don't page me...if I say it to myself enough times, maybe it will happen. I just want to sit here in the call room, play on the internet and talk to Skye on the phone for the rest of the night. It's been frickin' busy! 4 consults today!
Psych has been fun, I guess. I'm on outpatient service at the county hospital. My first patient was quite a learning experience. She was a tough one - crazy enough that she's really hard to follow and get a good story from, but not so crazy that you can forget about doing the history entirely and just assess mental status. She was a 50something African American lady with a history of psychosis who'd recently lost her housing because of her failure to adhere to the policies of the public program that had been supporting her. Unfortunately, she got the absolute worst psychiatrist possible. Totally unconcerned with her living situation, Dr. Feinhauer just wanted to give her a prescription for her symptoms - no social work referral, no effort to find out why this program had rejected her. The patient refused to take the prescription and left. Dr. Feinhauer is a petite Romanian lady who must be nearly 60 but continues to wear long, curly, blond hair. She was probably quite beautiful in her day. But she has a brillo pad of a personality. She makes zero effort to understand or empathize with her patients. She even gets irritated with the students if they talk to a patient for too long. "Don write a novel. Half a page, no more!" She just wants to give them a prescription, get them out and get home as quickly as possible. One of her patients, she didn't even see last week. I saw him - a schizophrenic man with depressed mood and difficulty sleeping.
"Dr. Feinhauer, may I present to you?"
"What have you got?"
"Um, er, shouldn't we talk somewhere else? Maybe your office?" We were in the reception area at the time.
"I see, patient G.F. Tell me."
I looked around, lowered my voice and realized I would have no choice but to talk about this patient in front of whomever happened to be passing by, "G.F. is a 58 year old man with a history of schizophrenia and dep-"
"Stable?"
"Well, yes but-"
"Then, you write," she handed me a prescription form "and I sign. Make another appointment for 1 month."
In a way this was kind of cool because I get to sort of play like I'm the doctor. In another way, it's much less cool - deeply horrifying, in fact. I don't mind Dr. Feinhauer on a personal level. I kind of like her. But I really feel for the patients who get stuck with her.
Dr. Wilson is a jolly, round-faced black man from Nigeria. I think he's awesome. He really listens to all his patients and considers his recommendation very carefully. He's also much more open to making a plan of treatment together with the patient's input than most psychiatrists are. I saw a 60 year old lady was a history of depression induced psychosis with him. I had already asked all the standard questions: do you hear voices?, see things other people don't see?, think about hurting yourself or others? etc. When Dr. Wilson came in, he asked some even more specific questions. He asked about a history of suicide attempts. The daughter, who was translating said her mother had attempted suicide twice.
"Ow did she do eet?" Dr. Wilson asked.
"She poured lighter fluid over herself and ran out in the street."
"Deed she tek off ha clothes?" This question surprised me. 'Did she take off her clothes?' Why would you even think to ask something like that? What surprised me even more was the answer...
"Yes." Amazing! How did he know? I forgot to ask how he knew to ask it. I'm sure I'll read about it soon enough, though.
On the same day, I saw another Spanish speaking lady - this one with an anxiety disorder. Only, it was the last patient of the day and there was no way to get an interpreter at that point. Her English was good enough that we got through most of interview alright, but when it came to asking about suicide ideation, she has some trouble understanding me. Then she offered, "My son is here. He translate."
Oh ok, I thought. That'll be swell. The son she was referring to was 10 years old! I won't lie, it's a little weird asking a 10 year old kid to ask his mom in Spanish if she ever thinks about hurting herself. She didn't seem to mind though. I did my best to make sure she would be comfortable having her son there for the types of questions I would be asking. And I think she was. Anyway, she wasn't having thoughts of killing herself, so that was good. I wrote out the prescription before she even saw Dr. Wilson. She believed her medications (an SSRI and a benzo) were helping. I guess that's all you can really ask for.

There was one patient that we had to put in restraints today. Up until now I thought I was pretty unflappable, but this really shook me up. It was an 80 year old African American lady with dementia and a seizure disorder presenting with an agitated post-ictal state. When I got there, the resident was already there, sitting on her bed trying to coax the patient, who was pacing back and forth in the hallway, back into her room. They called a security guard who made a wall of himself. The patient kept walking back towards him, as if testing for some weakness, some chink in the armor - she never struck at the same place twice. But each time, the wall would move, thwarting her attempt to escape down the hallway. The resident kept telling her that she needed to come in her room and take her medication otherwise they would have to give her a shot. They continued this dance for several minutes until the resident decided he was going to grab one arm while he instructed the security guard to grab the other and the nurses to handle the legs. The patient protested loudly for a few seconds but after that it was a simple process to lead her back to the bed, tie her down and inject her with some vitamin H (haldol). Discussing the incident with the resident afterwards, I made the assumption that she was admitted involuntarily.
"I don't know her admission status," he replied casually.
What!? You don't know her admission status? Isn't that kind of crucial? I'm pretty sure she has the right to leave the hospital whenever she wants unless she's either a)admitted involuntarily b)a danger to herself or others or c)lacks decisional capacity. Were any of these things assessed? Was any kind of protocol followed? The resident somehow weaseled his way out of doing a real assessment. "Well, we're covering for the consult service. They'll see her on Monday and probably admit her to the psych ward then, since she's medically stable. But we can't admit her now since there's not attending to admit to so we'll just keep her sedated until Monday."
I like to think that I would handle the situation better. Maybe I would, with experience. I could always do what that student in House of God did - raise the bed as high as it will go and have her admitted to ortho when she falls and breaks her hip.

Woohoo! Entry #100! Thanks for sticking with it, for those of you still reading.

Power to the people

2005-02-19T07:18:00.000-08:00

So, it's been a few days since I've posted. There a few different things I could write about. I'm going to give my readers the choice:

A. Fundraising party that my friend organized last night to raise money to save the show, Enterprise.

B. The crazy patients/crazy psychiatrists I'm working with now at the county hospital.

C. From the call room - stories of my day on call (today) along with some relationship analysis.

First person to comment gets to decide!

Origin of my anonymity

2005-02-13T11:47:00.000-08:00

I had a minor fit when I went to read mudfud's blog today and decided I needed to write a short dissertation on 'professionalism.' I never did include a 'rant' post in this, the latest incarnation of my blog, about why I had to stop blogging under my own name. It had to do with a certain disgruntled ex sending an anonymous (there's that word again) email to the administration that said something to the effect of "I'm worried about T.J., you guys should take a look at his blog. The upshot is, they thought my frank discussion of patient interactions and of my own thoughts was "unprofessional." I had problems with the word even before then, but now, I'm kind of on a crusade.

Gray day

2005-02-13T10:30:00.000-08:00

Rotations start again tomorrow - psychiatry. I need to kick this feeling of being on a permanent vacation interrupted by longer and longer stretches of long days, scut work and generalized obsequiousness.
I broke up with Kya. I was really hoping we could do the mature, adult thing and still be together while each of us sees other people. She's not down with that. It's only been 2 days since we talked and I already miss her. I don't know why I do things. For most of my adult life I've led a policy of act first, look at motives later. If I broke up with her, I must not care about her enough to do whatever it takes to make things work.
Sunday brunch with the intelligentsia this morning was scratch. People said nice things about the place I recommended, but I was quietly disappointed. The french toast was too sweet; I'd never had gritz before and probably won't again. And Katy was out of town so it was just Ken, his ladyfriend and a bunch of guys who were distracted with their own lives and the Sunday paper. I cleaned my apartment last night - apparently for nothing. They were all late for our reservation and didn't have time to come in.
I went to the international motorcycle show last night (giving away my city of residence). It was awesome - so many beautiful machines. Every motorcycle manufacturer had every current model on display. I couldn't have been happier if the entire conventions center was filled with naked women. I refrained from sitting on most of them. Sitting on a motorcycle and not riding it is like getting an unfinished blow-job...exciting, but ultimately very unsatisfying. I'm counting the days until it's warm enough to get my own Suzuki running again. I'm going to flip a coin now. Heads=look at porn, tails=do some reading for my next rotation.
Tails.
I'll do some reading. As soon as I'm done looking at porn for 15 minutes.

3 new posts

2005-02-09T16:19:00.000-08:00

Sorry the site has been idle for awhile. I was away in San Francisco and didn't get much internet time. Including this one, there are 3 new posts going up today. Check them out (feb. 6 and jan. 27).

I had Chinese for lunch today. Here's what my fortune cookie told me:

Your actions reveal your beliefs

I was very impressed with it. It's true. I watched the superbowl with Skye and one of Skye's classmates, Amelia and Amelia's boyfriend, Tim. Amelia and Tim live together. She's in a PhD program in psychology, he's a computer programmer. They live in a duplex and have the most beautiful place. Their house looks like a place where you would expect really hip retired people to live - not a young, unmarried couple. Immaculate, 2 cats, swank decorations, and everything in the place matched. I mean everything. From the drapes, to the couch to the chairs to their carpet, it was all part of a grand design. Even their china was a set, complete with serving bowls and appetizer trays. They make some great food for us and treated us to a minibar with 6 different kinds of red wine, 15 varieties of white and the ingedients for any mixed drink you cared to conjure up.
Amelia is Thai and our age. Tim is a little older. Apparently Amelia met Tim while he was a speed addict and then got addicted herself in order to show him she could quit and turn her life around. Amelia is gorgeous and both of them are such easy people to be with. We ate talked and only half paid attention to the game. During halftime, Tim asked us if Skye and I were into swinging. I talked it over with Skye. She gave the idea her obligatory hesitation but curiosity eventually won her over. Tim took her in the bedroom while Amelia and I made out on the couch. The sex was amazing. After we were done, Skye and Tim came and joined us, naked on the couch and we all cuddled and had a few more drinks and watched the rest of the game. When the game was over, we had another session on the floor. This time all 4 of us were involved.

Ok, now that I'm done making up stuff, here's what really happened. We watched the game, at a lot of good food and had some really good conversation. After the game, we played hearts. Not quite as exciting as what I had in mind but still fun.
I got home yesterday. Skye and I are scheduled for some long phone conversations over the next couple of days. I miss her. But, at the same time, I'm not sure it's working. One way or another, I'm pretty sure that what I do over the next couple of days will reveal what I believe about our relationship.

Is this the end?

2005-02-06T03:05:00.000-08:00

I'm in SanFrancisco now. I think I'm going to break up with Skye.
I had 2 weeks off in my schedule and I got a great deal on Southwest so I couldn't really come up with an excuse not to fly out and see her. It's a shame that our relationship is totally doomed because I really love her parents. Her dad's a chemist, her mom's a midwife - wouldn't it be great if you could marry your wife independently of your in-laws? I'd totally marry her parents. When we went to dinner at her parent's place the other night, her dad wore a sweater and a shirt and tie. Skye said, "My dad is never that dressed up. They must really like you." And I really like them. The problem is Skye.
We still connect really well, I just feel like we don't work well when it comes to the logistics of everyday living. She keeps asking me what I want to do. There are some things that I organize and take charge of. But right now I'm in her city. It would be nice if she could make a decision once in awhile - nice if she could offer an opinion on whether to drive or take the train, nice if she could offer an opinion on where to go after dinner and nice if she could drive anywhere without mapquesting it first.
We went out with her friend Ji Hye and Ji Hye's fuck-buddy, John tonight. Ji Hye is professionally attractive. She's Korean and has a big, pretty pumpkin face and tonight she wore black pants with a pink sweater that was more like a shawl covering her electric blue top. This guy she's with was visiting from LA. They were staying in some posh hotel together; he paid for dinner and for champaign at the bar afterwards - an obvious attempt at impressing Ji Hye in order to ensure that she sleeps with him. John's shyness did not cover up how self-impressed he was. He's what you get if you take a StarWars nerd, make him reasonably attractive and put a lot of cash in his pocket. Ji Hye was totally jealous of Skye. She kept shooting me glances throughout dinner and was definitely groping my ass at the club we went to after dinner. Skye didn't know it, but, for most of the evening, I was fantasizing about negotiating a "switch" with John. It's not something I've ever done before, but I would imagine that all 4 parties would have to be completely on board for it to have any chance of success. Even though Ji Hye knew that I was the superior boyfriend, she and John were the more attractive couple and I don't think the idea would've gone over well with...really anyone.
Skye's in bed waiting for me right now. Do I tell her tonight, do I tell her tomorrow; I can always wait until I leave and break up with her over the phone. I know it's stupid stuff....like, she she asked me what I wanted for breakfast when I woke up this morning. "Cereal," I decided. She poured the milk while I was still in the shower. It was mush by the time I got to the table. I know it's silly, but stuff like that scares me. What if I can only attract people who do things without common sense? What does that say about me?
I hope she's asleep when I get to bed so we don't have to have sex tonight.

Coed sleepovers

2005-01-30T21:44:00.000-08:00

I woke up in bed with my friend, Ken, this morning. It had been an interesting night. I got to his place around 11:30pm after taking about 1/2 an hour to park. It was a great spot though - right across the street. On my way to his place this girl who was obviously dressed to go clubbing asked me if this was Harrison street.
"This is Harrington street," I replied, wishing I could think of some clever way of engaging her in some further conversation.
"Harrington, that's right." And without so much as a 'thank you' she turned and began walking in the same direction I was going. When she started looking for Ken's name on the directory of his apartment building, I decided it was time to introduce myself. Her name was Anastasia (pronounced Anne-as-tahs-ee-uh). Apparently, she knew Ken from work. She had a gaunt, sharp face, curly blond hair and wore a black top and denim skirt that was slit up the front. She was quite the fiery bombshell - just the type who I would expect to ignore me most of the evening. My only defense against women like this is to preemptively ignore them. We exchanged some pleasantries and then I let Ken entertain her once we got to the apartment.
Turns out I was 180° wrong about her. She wanted to be talked to and seemed to appreciate even the smallest, most awkward gesture any of us offered at sparking her interest. The players were myself, Ken, 2 of Ken's other guy friends and Anastasia. This was a girl who I am sure was used to getting plenty of attention in any social situation let alone a 1 girl : 4 guy situation. Unfortunately, that's not how things played out. One of the guys was gay, and the other was this bizarre Puerto Rican man who didn't seem to notice that she was there. Then there is Ken who is just so sweet that you'd never know it, even if he was trying to hit on you. Besides, he was too drunk and high to give it much of a go. So, that left the burden of keeping this woman entertained squarely on my shoulders. Normally I would be more than happy to carry the load, but Ken had passed a little of the "good stuff" in my direction as well and I was in a state of the evening of barely being able to string together simple sentences let alone the sophisticated and witty dialogue I assumed it would require to keep Anastasia from being completely bored. So, for the bulk of the evening, Anastasia was largely ignored while the 4 of us chatted amongst ourselves. I felt awful. I wanted to apologize and say, "Gosh, I really would be hitting on you right now if I felt I could be a bit more coherent. But a combination of paranoia and lack of vocabulary is preventing me at the moment. Give me 3 hours and I'll be right with you."
Amazingly, she didn't leave. In fact, she spent the night. We stayed up watching the Australian Open final (next year, Lleyton), she crashed on the couch in Ken's sweatpants and tshirt and Ken and I shared his futon. I'm still not sure what to make of what happened. Was she really interested in Ken? Should I have left? Was she interested in me? Should I have made a move while Ken was asleep and I was watching tennis while she pretended to be interested? I woke up and went to brunch with the intelligentsia this afternoon. I hope we hang out again. Maybe this Anastasia girl can be the new Anne.

Since you've been gone

2005-01-29T09:42:00.000-08:00

I think whoever wrote the lyrics to that Kelly Clarkson song is having a joke at the expense of our entire culture. Ever see the video? She really seems empowered, doesn't she? She's strong, independent, comfortable with herself. You never see this guy who she's been "picturing herself with." Since he's been gone she can "breathe for the first time"...are you kidding me? He used her and she's damn upset about it! Hello, he "put her on," wrote her a "stupid love song" that she "fell for." And then he blew her off. Are we supposed to believe for a second that she's "so moving on?" If she's moving on, why is she singing about this guy in the first place? "You had your chance, you blew it?" That's just crazy. She just got done accusing him of not caring in the first place. If that's true, he didn't blow anything; he got exactly what he wanted - at her expense, by the way.
I think it would be much more empowering for her to say yeah, you used me and I'm damn upset about it. You can't at the same time maintain a position of, 'god, I miss this guy' and 'I'm too good for him.' Either he's great and you wish that he wanted you, or he's a jerk and you're better off without him. It's really that simple. But the singer says both of these things and what the song ends up doing is perpetuating the stereotype that women are crazy. If you want to sing a song about having been used, great - sing a song about having been used. If you want to sing a song about a jerk who doesn't deserve you, great - do that. Either one of those things would be empowering. But trying to win our sympathy by telling us how used you were and at the same time singing about how strong and independent you are - that's shows women to be neither strong nor caring and sensitive but instead fickle, overly emotional and easily manipulable. When you think about it, the song is actually pretty misogynistic, although it's presented as just the opposite.

First do no harm

2005-01-27T22:48:00.000-08:00

I saw my first penis surgery today. The patient had a disease in which the connective tissue of the penis contracts, but only on one side, causing it to curve ninety degrees to either the right or left when erect. I saw the patient in pre-op holding beforehand and was asking him about it. He was an otherwise healthy, intelligent and articulate 52 year old man. But when asked about his condition he could tell me about it only with an obvious and debilitating stutter. But when I asked about any previous history of anesthesia, other medical problems, etc, the stutter magically disappeared. It was very interesting.
We wheeled the patient into the OR. Fortunately I had a dentist appointment today and was able to leave before things too hairy. Urology is clearly not the profession for me.

The anesthesiologist I was working with today was a royal prick. There are 5 or 6 reasons why he's a prick which I'm not going to go into now; what's interesting about him is a conversation I overheard him having with another patient earlier in the day. The patient was a 59 year old lady with significant medical problems including coronary artery disease and COPD in for an elective spinal surgery. Justifiably so, this anesthiologist was nervous about giving her general anesthesia. But he kept saying over and over again - "We have a duty to first do no harm." He didn't want to do the surgery because of the possible harm of general anesthesia. Fair enough. But 'first do no harm?' You're an anesthesiologist. Anesthesiologists do nothing but harm. You're never helping a patient by giving them anesthesia. You're allowing the surgeon to help the patient. Whenever a doctor talks about first doing no harm, everyone nods and admires his wisdom. The principle alone of 'first do no harm' is total bullshit. Virtually anything any doctor does involves a certain amount of harm (or at least potential harm). 'First do no harm' really needs to be replaced with 'don't do more harm than good.'

To bigger and better things

2005-01-26T18:26:00.000-08:00

I ran into that ethics girl. I thought I would never see her again after she never paged me last week. She grabbed me in the hallway (almost literally) because she wanted to chat and catch up and say how she's really been meaning to call me. We made a date for coffee on Monday. After I thought our first "date" had been a disaster, she still seems to like me. She gave me an apple. Not that it matters now. Still going to do coffee though.
Anne's leaving tomorrow. I called her up tonight. They're all out having one last night at the bar. She tried to convince me to come. I very nearly gave in too, but it's really not worth risking the failing grade I might receive on our essay exam tomorrow. I'm really going to miss Anne. I wish I had taken the opportunity while I was still single.

Rubbing shoulders

2005-01-23T22:02:00.000-08:00

The club we went to for Anne's going away party last night was virtually empty on account of the horrible weather we've been having. People gradually left until around 3am when it was just me, my buddy Ken, Anne and Anne's friend Lynne. The four of us went to a new bar on the same block which was packed. It was a pretty posh place - you can tell they're trying to develop a reputation as being exclusive. There was no cover to get in. Once inside, Anne and Lynne slipped past a bouncer into a roped off section. Ken and I were stopped when we tried to follow.
"Ladies are free, guys are $20."
I was out of cash and ready to go home at that point anyway. But Ken, little devil on my shoulder that he is, paid for both of us to get past the large black man barring our passage. Ken is such a horrible influence on me - I can never say 'no' to him. It's amazing I ever got into medical school with Ken as my college roommate.
Being on the other side of the ropes was nothing special. There were plenty of hot women, but they were all hot in a perpetual club-goer sense - any reasonably fit girl who's dressed just right and done up enough is going to be hot. And considering the weather, it was only the hardcore professionals who were there anyway. Lynne was probably the prettiest one among them. She is just naturally stunning. Apparently, she dated Donnovan McNabb for about a week. She showed me his number programmed into her mobile. I called it and got a voice-mail message saying, "Leave me alone!" She said he was kind of sleazy.
I'm happy to say that I did restrain myself from getting physical with Anne. When the bar closed, we dropped off Lynne and the 3 of us (me, Ken and Anne) went to Ken's place to watch a movie, have some pizza and chill for awhile. Anne offered to share a cab when she eventually left. I elected to crash on Ken's couch.
I'm not sure what it was about Anne, but I'm really going to miss her. She and Ken are good friends and I've always asked Ken why they've never hooked up. He complains about how bitchy she is. But I think she's just the right amount of bitchy. Skye is great, she and I have a very real connection. But what I would love right now is to be dating someone who would just bitch at me and boss me around all the time. I love being told what to do - especially in a relationship. It makes things so simple. This is advice for any women reading this. Guys hate having to guess what you want. All we need are some clear, simple instructions. You may have to bitch at us here and there and make life unpleasant from time to time to make sure we follow through. But then we do, and everyone's happy. Alternatively, you could have a relationship where everyone is open and honest and communicates his or her feelings - blah, blah, blah. That's what Skye and I have. It works. Kind of boring, though.

The other side of the curtain

2005-01-21T17:57:00.000-08:00

Dr. Inly is the anesthesiologist charge of the medical students (4 of us right now) on my rotation. He's a tall, 46 year old man with a double chin and large belly both of which betray his otherwise svelt physique. He wears big, aviator style glasses and while he's surely among the biggest of dorks that ever got into medical school he is super nice. Dr. Inly typifies everything that distinguishes anesthesiologists from the neurosurgeons I was working with last week. To get into neurosurgery, it's necessary to lead a life where pretty much everything you do at every waking moment is in some way geared towards success. Those guys are well dressed, hard-working, were members of the most socially prestigious fraternities in college and have the most beautiful wives. They're great guys but they live life way above the speed limit. Dr. Inly, on the other hand, went to a small, liberal arts college where he played Dungeons and Dragons and entered robot-design competitions. In medical school he would collect various plastic caps, plugs, syringes and other disposables and glue them together to make space ships.
Trying to participate in the daily affairs of the neurosurgery residents, I felt a bit like a space shuttle re-entering earth's atmosphere. If I approached it too tangentially, I'd bounce right off and be of no use whatsoever. If I approached it too head-on, the intense friction of the endless, haphazard floor work would vaporize me. But, participating in the flow of anesthesiology is just that - flow. It's like rolling into a warm, slow stream and just letting the current carry you along. I've been so much more useful to the team. I've been learning more, doing more and I even have time to read when I come home! The difference between one side of the curtain to the other is night and day.
I was with anesthesia for a couple of Elaine Chen's cases today. She was the chief resident on surgery that I had such a crush on. I couldn't tell whether or not she was flirting with me today. Not that I would have to guts to act on it anyway. I'm just not confident that she would go for an other-side-of-the-curtain kind of guy, like me. Besides, I have a girlfriend now!

My new, so-called rotation

2005-01-20T16:31:00.000-08:00

Anesthia rocks! I love it. There's no rounding in the morning, your responsibility to your patient is done as soon as they wake up after surgery...it's great. And it's great as a student too. No progress notes, no keeping track of this or that study or lab result as they come in, the H&P's are really really simple, you get to do lots of stuff - intubations, a-lines - and once the patient is asleep, you get the pester the resident for all they know about anesthesia. Plus, you get to see all kinds of cool surgeries without having to hold a retractor! I think the only real down side is: could I get up every morning 5 years from now, look at myself in the mirror and realize that I was an anesthesiologist? For the longest time, I've had this stereotype in my head that the creepiest people in medicine go into anesthesiology and that anesthesiologists aren't real doctors. In a sense, they're not real doctors. They never diagnose anything, they almost never order any tests or studies. Nobody goes into the hospital to have anesthesia, they go to have surgery. Nobody thanks they're anesthesiologist for saving their life, they thank the surgeon. The anesthesiologist may save the patient's life, but only because they put the patient's life in danger in the first place.
Me? Anesthesia? I don't want to think any more about it right now.

# of IV's attempted - I've lost count
# of IV's successfully inserted - 2! Yes! Finally. I'm still better at blood draws but I'm finally getting the hang of this IV thing.

More to say, but I have a pounding headache. Those last 2 weeks of neurosurgery really sucked the life out of me. I got sick the other day and am still recovering. Still haven't gotten my watch back either. I'll call that girl again tonight. And yes, when I go to pick it up I will behave. I don't think I can make the same guarantee for this Saturday, though. Anne is moving back to Texas and I'm invited to her going away party. Am I really horrible? Or am I just a typical guy? Maybe "typical guy" is just a subset of all "really horrible things."

Another visitor

2005-01-15T18:09:00.000-08:00

Friday was my last day on neurosurgery. I survived! As cool as neurosurgery was, I don't think working 12-15 hours a day every day (including some weekends) is for me.
In addition to the ethics girl, who joined us again last Thursday, we had a visiting senior neurology resident join our service. Apparently, she's doing it as a 1 month elective. God, she was amazing: Asian, 5'10", broad shouldered and absolutely gorgeous. And not a bit snobbish about her appearance or intellect either. Just quietly confident, curious and with no compunctions about speaking up when the neurosurgeons were doing something she disagreed with. She didn't flirt with me the way the ethics girl did; she was just extremely outgoing and friendly. She taught me quite a bit in the two days that we were together and said she was going to be sorry to see me leave. She has no idea how mutual that feeling is. If I had known about this resident, I would've been sure to schedule neurology in my 3rd year. In just 2 days, this girl made herself a really integral part of the team. She would've been totally at home as a neurosurgeon. I told her she should switch. She said she probably would have if not for the fact that she delayed medical school in favor of grad school to begin with. If she were to switch and do a neurosurgery residency, she'd be almost 40 by the time she was an attending. I miss her already.

I met up with that ethics girl at a school function on Friday. She looks a lot like Willow from Buffy the Vampire Slayer but with a fuller figure. We have a lot in common. I think she likes me, but things were just really awkward and uncomfortable on Friday. It's not worth pursuing.

No crazy plans this weekend. That girl who was the focus of that indiscretion I had last week is out of town so I still haven't gotten my watch back. Serves me right, I guess. Hopefully she'll call next week - not so I can hook up with her, only so I can get my watch back - promise!

Forgive me father, I have sinned

2005-01-09T17:10:00.000-08:00

My stomach has been a perpetual stress knot for about the past week. San Francisco was great. I got there on the 28th. 5 nights and 8 condoms later, Skye and I are officially a couple.
Had brunch with the intelligencia again today. Ken's lady friend was there along with her girlfriends Liz (cute Asian from the holiday party) and Katy (really cool girl back from Nepal). Ken's lady friend and I have a good rapport going. I was really hoping she wouldn't ask about how things went in San Francisco. But she did - and I didn't have it in me to lie. Of course, this means that asking out her friend Katy is now out of the question - girls do talk, I'm told. It's probably a good thing. I already had a little indiscretion last Friday night with this girl I met at, of all places, a gay bar. Here's something I wish I had tapped into earlier: I'm thinking gay bars might actually be a really good place to pick up women. There's only a few of them there to begin with but the ones who are there have gay friends; they're most likely liberal - open minded. The rest of the guys there are gay - no competition. And if you clean yourself up, it's pretty easy to blend in. You can talk to a woman without it being obvious what your intentions are; I think it's easier to hit it off that way. If you don't click, move on; if you do click, somehow work the fact that you're straight into the conversation and you're golden!
I do feel awful about what happened, though. It was stupid. Skye and I are in different cities now, but I think we do have a really good thing going. I'm not going to see this girl again, and I'm wondering whether I should tell Skye about what happened. I think I should. It would really hurt for her to break up with me, but it's probably for the best. I think I would just end up hurting her in the long run.

The visitor

2005-01-08T11:59:00.000-08:00

We had a visitor on neurosurgery rounds this week. Girl, about my age, I saw her standing around as we were about to start seeing patients; nobody seemed to know who she was. Was she a visiting medical student? Turns out she was from ethics. How interesting! She's at our school doing a masters program in medical ethics - something I'm interested in doing myself one day (my undergraduate degree is in philosophy). She and I had a lot to talk about.
She saw the patients with us: we had one patient without decisional capacity in whose nose we had to keep reinserting a feeding tube that he would pull out, and a pregnant lady who needed an MRI but wanted anesthesia for the procedure. During morning report we go over the plan for each patient. The ethics visitor looked pretty bored throughout most of this until our chief mentioned something about a "slow code" for one of our patients at which she immediately perked up.
"What? Slow code?"
Oh dear. Our chief laughed nervously as he realized that he'd really stepped in it. Slow code is what is sometimes done for terminal patients with no chance of leaving the hospital. If the family doesn't agree to making the patient DNR, their status remains "full code," but if the patient does, in fact code, they sort of take their time getting there, maybe do 1 or 2 rounds of chest compressions and that'll be it. You can have whatever opinion you want on "slow codes" but the official stance of the medical establishment is that they are unethical. Our chief laughed it off and we moved on. The patient is still with us, as of writing this sentence.
Later, our visitor came and observed a temporal lobectomy that I was in on. Much of the procedure is done with a scope and all the medical student can really do at that point is watch on the monitor. She and I watched together...and chatted. We have a lot in common. She put her hand on my arm at one point during the conversation. While I was flattered that she was putting her hand on my arm and would've loved to continue flirting with her I was, unfortunately, supposed to be sterile. And now I had just been "contaminated" and had to go get a sterile sleeve to put over the area that she put her hand on. I think it killed the mood a little. But I did get her number (under the guise of 'I'd like to ask you some questions about the ethics program sometime') and I will see her again on rounds next Thursday. Yes!
Dinner with the family for my birthday tonight. It should be nice :)

Get rid of that stethoscope!

2005-01-04T20:49:00.000-08:00

So, I just started my 2 weeks on neurosurgery. I was wondering how long I would be on this service before I stopped carrying my stethoscope around. Answer - about 3 hours. We were about to remove a cerebellar tumor in a 25 year old pregnant lady today. I met the resident down in the OR.
RESIDENT: What are you doing with that stethoscope around your neck?
ME: Well, um- er...
RESIDENT: Get rid of it, it's pissing me off.
ME: (In my head) Gee, I mean I know this is surgery, but shouldn't we at least try to keep up appearances?
There are some cooky personalities. Later in day I scrubbed in on a spinal case. I introduced myself to the resident. He replied with a voice that was gentle although completely apathetic, "I know who you are."
"Oh, right. We met. And which resident are you?"
"It doesn't matter. I don't shave but I do shower."
That's fantastic. I asked his name that morning and he told me he was a medical student. I've met the guy twice, done a case with him and still don't know his name. He won't tell me! Maybe his name is Gacey or something.

Entries about San Francisco to come. Promise!

And so this is Christmas...

2004-12-26T02:37:00.000-08:00

Another Christmas gone by. Dinner was at my uncle's this year. Sister was in Germany with her roommate. My immediate family (mom, dad and me) knows that my sister is a lesbian. But, I'm not sure if anybody but me knows that her roommate is also a lesbian. They didn't used to be a couple. But they are spending the holidays with her family on another continent which rouses my suspicion more than a little.
Dinner at my uncle's was great. I ate too much - as always - but it was a good "too much." It was a "too much" that made me full and so then I stopped as opposed to a "too much" that leaves me lying on the couch, unable to move and in a hyperglycemic coma. It's those Greek deserts that always get me: (spellings are phonetic) coda bee ethas, baklava, galacta booty call - my parents made it with 24oz. of sugar! If you pay close attention, you can feel your insulin levels rising bite by bite. I had committed myself to one small piece and, only because I paced myself, I managed to get through it.
It's time to get my life in order for my trip to see Skye - leaving on Monday. Next entry will come from San Francisco!

Over-zealous dental hygienist

2004-12-23T01:07:00.000-08:00

So, I went to the dentist today. I'm not going to lie to you guys, it was the first time in at least a couple of years. I figure dental insurance is too expensive - I just need it every other year. Besides, never had braces, never had a cavity, my teeth are fine.

The dentist saw me first - very nice Eastern European lady. She did a quick exam and told me that my gums were a little inflamed and that, rather than the usual basic cleaning, I needed a full mouth debridement and that the dental hygienist would see me in a minute. She then promply scurried away. That was the last I saw of her.
"Full mouth debridement?" That didn't sound like fun. I figured I'd ask the hygienist what's what.
The dental hygienist came in and, let me tell you, I have never done so much talking during a dental visit EVER. First, she spent five minutes telling me what she was going to do, "My name is whatever, I care very much about your dental health, your x-rays look good (nice bone levels, no decay), I'm going to do my own exam, tell you what I think we should do and then, we'll talk about the full mouth debridement...yada, yada, yada" She did her exam, agreed that my gums were somewhat inflamed and explained that, it's a judgment call but that a full debridement would be better than a basic cleaning.
I asked the obvious question, "What does the full debridement do that the basic cleaning doesn't?"
"Good question," she looked at me as if she were ready to launch into a very long, very technical but educational monologue, "that's a very good question." It was a good question. It was a question that she didn't really answer by saying, "The full debridement is a more extensive cleaning. We just get deeper in there."
Oh, ok. Well, that sounded fine. I was about to tell her to knock herself out when she disclosed to me that "your insurance doesn't cover the full debridement. It's going to be an extra $100." So what am I supposed to think? Either my university gives us really crap insurance, or this was something I didn't really need.
"Why don't you just go ahead with the regular cleaning then?"
She smiled at me so sincerely. "Well, the thing is, I can't really do that. If I did the basic cleaning, more cleaning would still need to be done. And my professional ethics won't let me do a half-assed job like that. So, since I'd have to end up doing a full cleaning anyway, I'd have to charge you for it." Wow, dentists have professional ethics too. Who knew? "But you're so sweet and I really want us to agree on a plan here..."
What we eventually agreed was that I was going to make a special effort to floss over the next couple of weeks and then come back. If my gums were better, she'd just do the basic cleaning. If not, same situation. All in all, I spent an hour and a half at the dentist's office and didn't actually have anything done. All this just to agree on a plan for dental cleaning. I've seen doctors take much less time with patients in formulating a plan on how to treat cervical cancer. But, she did sell me on the flossing. Just finished flossing before writing this. I think I just lost about a pint of blood. But I can't wait to walk in there in 3 weeks - my Hb will be down to about 6.0 but gums will be completely healed.

God, it would suck to be homeless in this city

2004-12-21T22:26:00.000-08:00

I suppose it would suck to be homeless in general, but particularly with the harsh, unpleasant winters we have here. There's a homeless shelter about 4 blocks from the hospital I work at. A group of medical students go there to volunteer once a week along with an attending. It's different people every week; most students go once or twice a quarter. This was my second time - first time as an M3. It was pretty cool to have more knowledge than someone else for a change (namely, the M2 I was paired with). The flow of education is pretty exclusively top down: attending -> resident -> medical student, so it was nice having the flow terminate in someone else besides me for a change.

Had dinner with Min before that. She called me earlier in the day asking for advice on how to cope with surgery. When I called her back I thought, hell, I'm alone tonight, she's alone (as far as I could tell) why not make those dumplings she gave me a year ago which were still sitting in my freezer? It was nice. We ate and then watched a couple of episodes of Arrested Development that she had ordered from Netflix - brilliant show, by the way. Why is it that this girl, the best relationship of my life, the person I was ready to marry...I can be around her without getting crazy and yet that disaster that happened 5 years ago...seeing her picture online gives me heart palpitations. I hate to admit it, but she looks frickin' amazing in the pictures she has on her website - trim, great teeth, wears jewelery now, killer hairstyle. Obviously she's trying to attract some attention. And, I've said it many times before, if you're a reasonably attractive woman it's not at all hard to find a guy who will sleep with you. She's not in college anymore though; I don't think she'd go for the one night stand thing. There's really no point. She needs a stable, reliable fuck-buddy.

But, what do I care? Why am I even writing about this? I'm going to stop now and go to bed. I'm going out with Ken again tomorrow. We'll have to work on rounding up Anne and the Philipino squad. I think I must have been Asian in a former life.

Picture of mental health

2004-12-21T14:05:00.000-08:00

So I just spent the entire day reading the blog of one of my ex's. Unfortunately, posting the link would reveal my identity as her blog is not anonymous. This was in college, before Min. A link to my old blog would've told the story but, the long and short of it is she left a pretty permanent scar that more or less bisects both atria and ventricles with a quarter-sized area of fibrosis at the AV junction where she twisted the knife a few times. You can join the story at the place where we met up again about this time last year. I had recently broken up with Min, she had recently been dumped by her boyfriend of 2 years (I learned this by reading her blog). I got the bright idea that we should catch up. She affected me in the way that I absolutely knew she would; I went immediately from being broken up over Min (good, healthy relationship) to obsessing over what I had lost with her 4 years ago (bad, unhealthy relationship). I guess I was hoping to recapture something.

Ok, here's the part where she becomes evil. We caught up over coffee one evening. There were multiple opportunities for her to leave, but she stayed. She let me give her a tour of the hospital, stood very close to me under the umbrella as I walked her to the train and hugged me good-bye for just a little too long. She only left at all because it was like 2am and I told her I had class the next day. This was about 2 weeks before she would sleep with her favorite fuck-buddy for the first time. And once that happened, believe me - there was no more sharing of umbrellas. It's taken awhile but I'm not illiterate anymore; I can read the signals. And I was definitely responding to something that wasn't there anymore once this other guy agreed to sleep with her. Of course, like a moth to a flame, I continued to pursue. She, of course, didn't like it and used the fact that I had read her blog as an excuse to hate me. And that was that.

I had abstained from reading since March 23 of last year. It was a good run. She subsequently developed some sort of intense romance with that guy (like I didn't see that coming). At least she doesn't sleep around too much. Her MO is to find one guy who is willing to fuck her and be there for her but who doesn't like her too much. That was the problem when she and I were together. This orchestra director of hers fit the bill perfectly. That ended, as it was bound to, when his ex came back and now, as far as I can tell from what she writes, she ain't gettin' any right now. Which will always make me happy :)

New Year's plans

2004-12-20T10:51:00.000-08:00

So which one of these chicks will you be kissing on New Years Eve? :)
Dawn (webmiztris)

That'll be Skye, since I'm going to be visiting her in her beautiful, costal city over New Year's. Unfortunately, this is a trip that, I think, can only end badly. Skye has been telling me lately how she wants us to be either in a committed relationship or to break it off completely. Well, with Skye living a 3-5 hour plane ride away, the committed relationship thing just isn't going to happen. Making that work would entail not seeing anyone else for the next year and a half and then finding a residency program in her city specifically to be with Skye. And in the meantime, we'd probably get to see one another a grand total of 4 or 5 times. The only woman I've ever been with who I would rearrange my life to that extent for was Min.
Speaking of which, I just ran into her last Friday, after the surgery miniboard. I somehow manage to avoid her for the past 6 months and then I run into her on the last day before break. We chatted a bit - nothing has changed at all from my perspective; I'm just as much in love with her now as I ever was. She's dating some Chinese loser now. We don't talk or see each other anymore and I think it's for the best. We broke up almost a year ago now. And it took me about six months to finally embrace all that is good about being single.

Holliday Party

2004-12-18T23:49:00.000-08:00

Quick updates before I fall asleep:
So, we had our holliday party tonight. My friend, Ken, who was hosting it sent out a hillarious video invite. His lady friend (the one who introduced me to Katy) brought some interesting people. Two girls named Liz: one of them was Asian, the other was a law student and another one who was a nurse. The Asian was so cute! I thought Ken's lady friend had brought her just for me. We hit it off for about 6 minutes when she casually slipped mention of her boyfriend into the conversation. I kept talking to her, but my heart wasn't in it. Oh, who am I kidding? My heart was still completely in it. She was just so cute! And so easy to talk to. The law student was pretty but I think she and I had a mutual disinterest in eachother. Then there was the nurse - a nurse at the same hospital where I go to medical school, as it turns out. She was cute, but overweight. But fun to talk to. She was wearing jeans and a loose sweater which made it really hard to assess exactly how overweight she was. Because, you know, a little extra can be really nice. I just wasn't sure whether or not she had crossed the threshold. Her face and neck were lean - no double chin or sagging cheeks, so that was good. We had a really nice conversation. She and her law school friend left pretty early though, along with the Asian one. Maybe I'll see her at brunch tomorrow. Katy would be there but she is,unfortunately, in the same costal city where I will be visiting Skye next week. Our time there will overlap for a day. And Skye actually will be in Hawaii for that first day. Maybe I should try and contact her.

Gideon, another of my high school friends was there. Last time I talked to him was last fall and what I said was something to the effect of, "Where are you, you bastard?" I had invited him to a party at my place and he basically just forgot about it and made other plans, then left for law school the next day. I've always really liked Gideon. I wish he'd make an effort to hang out with me once in awhile rather than it coming always completely from my end. Gideon is tall, lanky, very much a pretty boy. He was one of the star actors in our class. He's smooth, charming, athletic; if I was a woman, I would totally date him. Gideon had just ended the first serious long-term relationship of life the previous summer. The girl he was dating was a PhD student in Spanish Lit. She was a little introverted, but smart, ambitous and very pleasant to be around. I fist met her when they first started dating - damn sexy body too. The only other time I met her was last summer. She had gained some weight - a significant amount of weight actually. But still damn sexy. I wonder if that wasn't part of the reason Gideon broke up with her. The upshot of this little sidetrack is that Gideon told this gut wrenching story at the party tonight about how he called this girl up after not speaking for 6 months and how she had completely changed in all the right ways and how he was again wishing he had taken her up on her offer for them to spend the rest of their lives together. Long story long, he asked for her back, she waited 6 days and said 'no' and, oh yeah, she has a boyfriend. Oh well. I feel bad for him. but I'd feel more bad if the bastard would call or shoot me an email once in awhile.

My Palm Zire 72 came today - Yay! I'll be playing with for the next few hours. Next post will be tomorrow and it will be about brunch.

Shot down

2004-12-18T08:55:00.000-08:00

So, my Korean friend has to "spend time with her family" tonight and therefore isn't coming to the party with me. I asked what her plans were for the break, "...spending time with family." Ok, geez, I was just making conversation; I wasn't going to try and ask you out again if you had said, "Nothing."
Whatever. Lots of chores on the agenda for today including changing the oil in my motorcycle so I can store it for the winter. Will update on how the party goes later tonight or, if things go well, sometime tomorrow.

Is that the clitoris or the urethra?

2004-12-15T20:15:00.000-08:00

Having now successfully completed 8 weeks of surgery, I think I've gotten pretty proficient at putting foley catheters in people's urethra's. So, we've got a female patient on the table - I've tested the balloon, catheter tip is all lubed up, patient is prepped and we're ready to fly. Now this particular patient is 82 and overweight so there is some spreading to do in order to access her urethra. Rodrigo, the new chief resident, is helping me out and I'm about to insert it when he says, "No, that's the clitoris."
"Are you sure," I looked back at him. "I really think that's her urethra."
"Nope, that's the clitoris. The urethra's down there," he pointed to a dimpled area about a half centimeter below. "Right there."
"Ok..." I gave it a try. No advance. After it became totally clear that the little dimpled thing was not, in fact her urethra, I went for my original spot. Catheter tip slipped right in and golden liquid flowed into the tube. Vindication! I'm know more sure than ever that I am meant to be an obgyn. Our new chief may know more surgery than I do, but he's kind of an idiot. I miss Elaine.

Speaking of our old chief, Elaine Chen, I sat next to her at grand rounds this morning. The lecture had something to do with repair of abdominal aortic aneurysms, but I wasn't really paying attention. I was too enraptured with Elaine...taking in her smell, watching her suck on her candy cane, wondering what would happen if I put my hand on her knee. She bit off a piece and began chewing. I looked over and she broke off a piece for me too. God, I'll miss her. One day I'll be chief. And maybe some bright eyed, third medical student will take a seat next to me at grand rounds. She'll rack her brain thinking of an intelligent question to ask me so that she'll have an excuse to turn around and put her hand on my arm. I like the way my future is looking.

I was examining a patient we were going to do a cholecystectomy on. He was an inpatient which meant that he had a complete history and physical in his chart - done by the person who had admitted him. The person who admitted him happened to be a fourth year medical student, Fasana, whom I had worked with when I did pediatrics. Too much to go into now, but she was a real piece of work - just take my word for it. She is apparently doing her sub-internship in medicine right now and, furthermore, she happened to be the one who admitted this patient. It doesn't take long for a medical student to learn that not all H & P's (history and physicals) are created equal. Some give you everything you need to know about the patient, others are woefully incomplete. Looking at Fasana's H & P , I became rather jealous. It was great, thorough, well organized, ledgible. Then I looked at the physical exam part of the H & P: "Lungs - CTA (B)" - stands for "clear to auscultation bilaterally." Clear to auscultation bilaterally?! Hmmm... I went to examine the patient. He had a scar on his right side that began on the back, just below the ribs, and extended laterally to about the midaxillary line. I percussed : he was resonant on the left side, dull on the right side. I listened : he had breath sounds on the left, nothing on the right. I checked the chart. The patient had had a right pneumonectomy! He absolutely wasn't "clear to auscultation bilaterally," he only had one lung! I was less jealous after that.

Home stretch

2004-12-13T17:40:00.000-08:00

2 days of surgery left.
I had brunch with the intelligentsia on Sunday (post call day for me). There's a core group of about 5 of us for whom this Sunday brunch has become a weekly tradition. We discuss politics, complain about the gentrification of urban neighborhoods, wallow in our misery over the election and (when the ladies aren't present) we talk about the ass we've gotten - or wish we had gotten. Basically, it's a time for us all to congratulate ourselves on how smart, sophisticated, liberal, good-looking and successful we all are. I love my guilty pleasures!
There was new member at the Sunday brunch this morning - Katy. Katy is one of the coolest person I've met in a really long time. She graduated at the same time I did and has spent the last 2 years in Nepal teaching English. How cool is that? She's awesome. So frank, so curious, so positive, so open. Unfortunately, she won't be at the holiday party that the members of the intelligentsia are having this Saturday. Disappointing, but at least it clears the way for me to invite my Korean friend who, incidentally, I had lunch with on Friday. I was very proud of myself. I just sent her a text page saying, "Meet outside housestaff lounge in 5 min 4 lunch." I gave myself 40 - 60 odds: 40% chance she would show up and 60% she would blow it off. To my delight, she showed up, got some cash and we went and got lunch. I think she actually blew off a case she was supposed to be at. I have to like my chances here. Anyway, next step is to find the exact right time to ask her to the party. I will probably spend the better part of Tuesday evening trying to figure out the best way to make the invitation seem like an afterthought.