laughter makes everything so much easier

I keep finding that the docs I work with use humor to diffuse the stresses of our days. It's a relief since it's one of the mechanisms I use most frequently.

We tease couples who have been married for more than 60 years for not listening to each other.

We pretend that we are going to use the largest needle possible to perform a digital block.

We talk about patients who make us nuts in humorous, if dark, ways.

We find reasons to laugh with our terminal patients - their loss of hair, inability to control their farts, whatever joke the patient has made at their own (or our) expense.

Patients use humor defensively as well. It's one of the few ways they are able to speak the same language as their docs.

Rural Medicine is where I belong

I had the absolute best day yesterday. It started off with me being late. Nothing out of the ordinary. And I went to the wrong room. Also not out of the ordinary.

In the wrong room, the nurses prodded me with questions about me and my partner; generally tried to make me feel welcome.

Made it the OB rounds where I was supposed to be which was mildly boring but incredibly educational. I love being able to learn.

Then to the emergency department. It was a busy day - 4 ambulances, lots of walk in patients. We also had 4 admissions. Wackiness.

We've had a patient with inoperable gut cancer that was an "orphan" patient my preceptor picked up. She has been bleeding constantly since admission and suffering from melena and diarrhea. In gynecology, when a fibroid bleeds too much and the woman requires as many transfusions as my cancer patient does, we consider embolizing the arteries feeding the fibroid to kill it. I didn't understand why this hadn't been done yet so I asked my preceptor who told me to ask the specialist who gave me multiple reasons including "because we don't do it". That's fine he's the specialist not me. Through the week I helped the patient with edema, anemia, increasing food intake, decreasing diarrhea and generally feeling like she and her husband were part of the health care plan.

Last night we transferred our patient to a higher care centre. The specialist was on the phone with my preceptor and told him that they planned to try to embolize the tumour, to which my preceptor responded "oh, isn't that what my medical student suggested last week?". I love this preceptor.

The patient's husband went over the plan with me one last time before the transfer. He'd had a horribly stressful week which he had the nasty habit of taking out on me and the staff. He cried and gave me a big hug before leaving and thanked me for helping them through their week.

In the afternoon all doctors were asked to report to the delivery room ASAP. We ran down the hall and entered to find a shoulder dystocia that wasn't going well. Since so many doctors made it to the room, after the baby was out, I stood back and watched the baby resuscitation (which went well). Dad was also quite far against the wall. Mom was freaking out because baby wasn't doing very well yet. I told him, in my very firm, no nonsense voice, that it was his job to hold mom's hand and keep her calm. Which he did. And that was good.

CaRMS is in

For my birthday my partner took me on an all inclusive trip to Cuba. Fantastic.

We left the Sunday before my residency applications were due which was a bit stressful but I felt like I was ready and had no concerns about my app.

The trip was brilliant - warm water, white sand, carefully screened sun and abundant rum.

The day my application was actually due, I logged onto the very slow, very expensive internet at the resort and checked in on my application. I've made it abundantly clear that rural medicine is for me. Imagine my shock to discover that my rural essay had not made it into CaRMS's hands. Horror of horrors. Seriously.

I ended up having to paste my essay into the small spaces available for me on the CaRMS website, sacrificing other aspects of my application to ensure that the program gets my wonderfully crafted essays about how I belong in the country. Gah.

But, in practice for the day that I will be a physician and need to leave bad days at the office, I finished, freaked out for 1/2 an hour, then jumped in the pool to enjoy the last few days of my vacation.

Stressful? Yes. But I think I'd finish my app early and leave the country again. It meant that I wasn't around while the rest of my friends were freaking out and causing me to stress.

Plus, of course, rum. Tasty tasty rum.

there are so many ways to avoid doing my essays for CaRMS

tonight it's silly movies

Touch

We were out this weekend to listen to live music (the best way to spend the weekend in my opinion). I felt somewhat uncomfortable because so many of my partner's friends, and mine, were very touchy. Rubbing my back, my arms, holding my hand while they spoke to me. Even hugging these folks I hadn't seen in months felt strange.

Growing up, my family was not terribly affectionate. It was something I'm proud of cultivating with my younger siblings. We hugged, kissed and snuggled. Now when they talk to me on the phone they say they love me, we hug every time we see each other.

But I'm not that way with other people. My very good friend in the class mentioned that we don't hug because "I didn't think you were a hugger" - however when I recently met her mother, it was the first thing we did after saying hello.

My idea of touch has changed dramatically since entering medical school. There are several kinds of touch as I see it.
1. The "hand shake". Typically done at the beginning of a new experience with a patient.
2. The "my hand is on your shoulder now because I'm using my stethoscope" touch. It's mildly familiar, helps me know when the patient is breathing if there is too much consolidation to hear well and gently reminds the patient to hold still/not speak.
3. The "this is something I have to do clinically touch". Reserved for DREs, breast exams, pelvic exams, genital examinations. It's all business, get in, get out.
4. The "you're having a really bad day" touch. I'm comfortable with this one even though it's bordering on quite familiar. When I am chatting with a patient with some sort of terminal illness or who has been in hospital for a long time, or with whom I am sharing bad news, I automatically rest my hand on their leg or hold their hand. I worry sometimes that this is more paternalistic than it should be. It's not intended to be, it's how I deal with people having a bad day.
5. The "tickle fit". Strictly reserved for kiddos under the age of 3 who are mostly feeling well. I call it developmental observation.

It seems like my comfort level with touch is divided into two categories - family and non-family. Time to split the second group into friends and patients.

CaRMS is rapidly approaching.

While I know I should have no problem explaining why I want to be a family doc in my personal letters I still find myself lost for words. I blame not writing here. So this isn't procrastination it's work. M'eh whatever.

I've been working with docs who help Canadian newcomers and refugees. These patients are teaching me so much.

I'm learning to be patient. Our interviews take at least twice as long since all questions and answers are filtered through an interpreter. My vocabulary often doesn't match either the patient or their interpreter so I need to come up with new ways to describe what most Canadians are easily able to recognize (e.g. weight loss).

I'm learning that some things make language unnecessary. Making faces at children, laughing, smiling and drawing pictures of flowers, friends and homes.  

I'm learning to laugh. Try doing a cranial nerve exam on someone who has no idea what you're doing. Hilarity will ensue I assure you.

I'm learning that my life is brilliant. I've never been shot. My house still stands. I haven't watched while someone I love was beheaded.

Learning daily from my patients will be my favorite part of being a doctor.

oh no, I forgot to pack my lunch

guess I better treat myself to yummy Thai while I'm here in KW

have I mentioned how much I love electives?

family medicine elective

I am loving this elective. So glad I decided to apply to family. It just keeps getting better and better.

health clinic in a residential area

so cool

Uploaded - 05\10\2010-2

"Things will get easier, people's minds will change, and you should be alive to see it"

I know it's cliche, but our media is not doing teenagers any favours.

Ellen's talk about the teen suicides in the US that are following bullying is powerful and long overdue. Not just by her, but by adults and media in general. Everywhere they look, media is focused on teens and telling them what to do, how to look and who they are expected to be. Bullying isn't just taking place by other kids targeting children kids who are different, who may or may not be gay.

Idiots on the net are suggesting that the kids who are killing themselves to escape the bullies were mentally unstable before the bullying began, that being gay is a form of mental illness. They clearly forget how hard it is to be a teenager. It's incredibly difficult to keep your wits about you while figuring out who you are and dealing with surges of hormones. There are few teens who are mentally stable to begin with. Add bullying to the mix and it's surprising there are more episodes of suicide than there already are.

I was one of those kids who was teased about being gay before I had discovered for myself that I wasn't. To me though, this teasing meant nothing because I didn't see anything wrong with being gay, as long as they didn't call me fat or stinky I was OK.

Again, movies, TV and magazines tell us that if we do things perfectly -by wearing the right makeup, dressing in tight clothes, sleeping with whoever we please, drinking alcohol and still being brilliant at school, friendly, athletic and thin - we will have more friends than we know what to do with.

No pressure.

Hard to imagine why kids struggling to define themselves are struggling so much. Each teen is fighting this battle and has a difficult time recognizing that they have peers fighting similar battles. It results in them feeling isolated and ignored and trying to find a way to be seen. They become bulimic, goth or emo; buy crates of makeup and perfume; dress like sluts; slowly self destruct.

I've spent a few weeks with the child psychiatry team and these messages and how teens deal with them have been at the forefront of my mind. There isn't a fast solution to the problem which seems to be systemic. All I can hope for is a change in the content of the messages being broadcast to our youth.

Imagine you're a ten year old kid. Your thinking is still very concrete; sarcasm and shades of grey are completely lost on you. If someone tells you that you are too chubby you believe it. If someone tells you there's an obesity epidemic - that being fat is unhealthy - you believe that too. Then you start to pay attention to other messages from media, school, peers and adults. Foods low in calories, low in fat and sodium are healthier choices. Empty calories that you get from foods like the pop and chips you enjoy occasionally with your family are not good. Rules for eating and exercising begin to be formed in your head, all because you want to be more healthy.

Congratulations, you now have an eating disorder. Not because you think that you are too fat and need to look better, but that you are unhealthy and want to become healthier. Without countering the restrictive messages with messages of balance, enjoyment and the importance of certain nutrients like fat, this ten year old can become an eleven year old who is so malnourished, has a heart that is so wasted of muscle its SA node no longer function and an EKG tracing shows a junctional rhythm. The only option is to put this child into the hospital, provide him with nutrients at a rate that will not cause refeeding syndrome, and teach him the way to feed himself in the future - a balanced approach to be healthy.

Adults and especially health care professionals have a responsibility to keep the messages kids receive safe. Ellen is right. This is a crisis.

My Infectious Disease Elective

One of the most important parts of acting like an adult learner - rather than just another med student requiring to be spoon fed - is going into clinical experiences with your own list of personal objectives you would like to meet.

While these may not always be met, it gives you an opportunity to guide your own learning. My personal objectives before starting infectious disease were very simple. I wanted to know how to treat the types of diseases I would see in a family docs office. This wasn't at all accomplished in my 2 week rotation, but I did end up with a completely different learning experience than I expected.

Our days went from 8:30 to 5:00, starting with going through our patient list and ensuring that lab work was within limits from an ID perspective (liver enzymes, drug levels, neutropenia, etc.) and that our patients were still on the level of anti-infectious agents the team had suggested. As a consult team, we make suggestions about the care of a patient, but it's up to the patient's primary team to agree or disagree with our recommendations.

We would also be paged from other services asking for our opinion on treatment options for their patients. These were for patients who were allergic to most meds, had a resistant type of infection, had no identifiable source of infection, were HIV positive or just generally were a bit too strange for the team to deal with.

Some half days were spent in the HIV patients in follow up or to start those recently diagnosed as being HIV positive with a drug regimen.

The list of things that I learned on this elective includes:

1. How to find the source of infection when it's not immediately obvious. This can include scraped skin on carpet after an elderly patient has fallen, a pneumonia 6 months before osteomyelitis and hepatitis secondary to needle sharing in the '90s.

2. How to use my Sanford Guide. This book is brilliant!

3. HIV care has changed dramatically since my friends were diagnosed in the 90s. One pill once a day. WTF? It's amazing. I'm still in awe.

4. Hospital staff are incredibly prejudiced about our patients with HIV and Hep C. I wish I could teach them all to behave like good boys and girls but feel this could take a very long time.

5. I can see myself adding an infectious disease element to my family practice, likely HIV and Hep C care.

http://www.sawdustbear.com/marlowe/?p=54

health care management

I'm taking this night course in which the business doc reminds me of that professor from Harry Potter who "collects students". Only he collects important people.

big men walking little pocket dogs

These guys always act like they are so surprised there's a tiny dog attached to the string in their hand. It's as though they think that if they look nonchalant enough that no one will know that the dog is with them.

The truth is, I know, that they cuddle and snuggle these dogs at home and love them to little bitty pieces.

more strange attitudes

I recognise that many people in the hospitals have seen things that are horrific, have been burned by patients and are genuinely jaded by their work.

It's still disturbing when nurses and docs are judgemental of patients who say they are trying to kick their iv drug habits; are pessimistic about patients who are HIV positive.

These patients are peoples' fathers, daughters. They are loved. To treat our HIV and IVDU patients as less than deserving of care does a disservice to the patients themselves and the people who love them.

Diagnosis, Sesame Street

Silly, fun.

I always thought of The Count when studying OCD. Nice to know I'm not alone.

electives!!

This is an entirely new way of learning for me. Rather than learning things for the first time ever, I'm adding to what I already know.

I know how to write a progress note, take a history, do a focused physical, present patients, write orders and scripts; know most pysch meds, pain meds and iv solutions though very little antibiotics. I'm comfortable doing many procedures like suturing, casting and catheterizing.

This is my chance to get better. A lot of my class is using this time to become more competitive and get letters for CaRMS. That's probably a good idea. I'm not doing that though. It worries me that I may not get the program that I want most, but if I don't take this opportunity to take advantage of things like an Infectious Disease elective, I know I'll regret it.

Losing a patient

Today was the White Coat Ceremony for the class of 2014. It's an enormously emotional event. The deans talk about the friendships that will be forged, the lessons that will be learned and the incredibly journey these first years are about to embark upon. They talk about the support of family and friends that have allowed us to reach our potential.

It's incredibly stirring. I teared up. My friend teared up. We have seen how important those friendships, lessons and family have been on our journey. We knew exactly what he meant when describing the patient that we would have to tell is suffering from a terminal illness. We remembered the hope and anxiety we felt as we waited to don our own white coats.

Several members of the new class also got a bit watery eyed. It's easy to become so happy, so anxious, so overwhelmed with the event that the only release is to cry. It's a tremendous day.

All of the new members attempted to hide their red eyes. They were embarrassed to be showing so much emotion in front of their now colleagues whom they had yet to meet. It's seen as being weak and unprofessional to cry, nothing like the wonderful physicians the deans had just described.

And this all reminded me of one of my favourite patients who died while I was on call.

He had a mixed bag of ailments despite being younger than me. We started every morning's rounds with playful flirting back and forth. He was everyone's favourite patient.

On his last morning, we knew something wasn't right. He'd had a bit of bleed during the night, but not enough to make him look so wrong. He was tachycardic, but no more than usual. He was also alternating between cold sweats and not - something he assured me was normal for him. He was scared though and that made us scared too.

My resident and I checked in on him several times during the day. We ordered and followed up on a slew of tests. We chatted with him and his family, checked in on what the nurses were thinking and tried to stay on top of an otherwise incredibly busy shift. Nothing seemed to be glaringly wrong.

Late that night, my resident and I ran into each other outside our patient's room. I hadn't been paged, just wanted to check in. The resident had been paged that our patient was unwell.

He had gotten up for a walk, become quite dizzy and unable to continue walking.

He was also a colour that let me know things were really wrong. His colour, stagger and perspiration look like the Netter's cartoons of patients in haemorrhagic shock. Seconds after I saw him, we had him on the ground and called the code. It felt like seconds later he was in the ICU and a row of intensive care nurses and PSAs were taking turn performing compressions while the residents called out the drugs to administer in sequence. They tried to keep him alive until his family was able to arrive. They worked like crazy for our patient they had never met.

TOD was called more than an hour before the family arrived. The new team of nurses took over and prepared our patient for his family to see him. They cleaned him and propped him up in bed. If it wasn't for the non-functioning endo-tracheal tube sticking out of his mouth, we might have been able to believe that he was still alive.

I went in to thank these nurses for helping and told them how important this patient was to our team and his family. And I cried. I couldn't stop. But I didn't want my team to know that I was crying. Heaven forbid they know that I care so much about this patient I had spent so many hours caring for and talking with. The nurses hid me in the room with them and told me it was perfectly acceptable to cry. They helped me pull myself together before going out to see my team again.

We met with the family and our senior for the shift (not a member of the original team) went over what had happened. I kept my head down and quietly cried, wiping my nose on the sleeve of my hoodie. Once the story was told, the family broke down and we left them alone. Grandpa grabbed my hand on the way out the door, didn't say anything, just held my hand and cried.

Our consultant came to the hospital as soon as she heard. Usually an incredibly stoic woman, she was silently crying while going over the last CT we had ordered. We went through all our actions of the past 24 hours for what felt like the 59th time while our consultant quietly nodded, asked some questions, then said "You did everything you were supposed to do. Thank you."

It was exactly what we all needed to hear.

While I get that it's no good to go to pieces when we have bad days like these, I don't think we need to entirely hide our emotions either. I worried during our family meeting that the family would think that I didn't deserve to grieve with them. This was in my head, I don't think they could have possibly noticed anything outside their own grief.

Crying is how I express so many of my emotions. Sadness, anger, frustration, happiness. I wish I didn't always feel the need to find a place to hide when I need to do it, especially since I'm not the only one. I hope I remember to tell my clerks that it's OK to cry, laugh, hiccup and do whatever we need to do during our day to be ourselves. It's so easy to get lost in the business of filling out forms, performing procedures then dictating them, desperately trying to discharge patients to make space for the ones clogging up the ED that we lose the feelings we had on our first day of med school.

Clerkship is over, let the slacking begin

I've been watching a lot of Grey's Anatomy. Realizing I am exactly like Izzy. Overly invested, bake to deal with stress, but much shorter and much less cute. Cute isn't everything. Figured I would do the quiz for kicks to find out

I made dinner tonight!

It's been so long. I love being able to put together a healthy yummy meal - feel so productive.

yesterday I also sent off a paper to the school journal

it's been ages since I've actually finished a project and I'm amazed by how much better I feel

I've been trying to write at least 15 minutes a day which according to my book "writing your journal article in 12 weeks" (cheesy title but a fantastic book). It's been great to get me moving forward on some of my kabillion projects I have on the go.

It saves me on days like this when I have residents who act in silly, petty ways.

no more clerkship exams

no more call until residency

campfire and friends

summer begins!

you can have ice chips

It always seems so strange that patients are so grateful when we let them eat ice chips, pee without a catheter walk with the freedom of no iv's. On my psych rotation we handed out smoke passes to patients who were well behaved.

If patients make enough urine, out goes the foley.

There is such a huge amount of power given to the docs over their patients' smallest and most basic bodily function. Things everyone takes for granted.

the morning after my last call shift of clerkship

what a crazy night

I can't wait to sleep

more apps I'm using in clerkship

As far as organizational apps I've added, my favourite are calengoo and toodledo, but not just for their fun names.

CalenGoo:
Made to sync with your google calendar. I use this instead of the native calendar because I love my google calendar. You can set it up to text you before appointments, colour coordinate different aspects of your life, set up repeating appointments. Information is stored so you can access it off line, sync when you have an internet connection. There is an option for including details of your events. I usually cut and paste the information from emails into this space, e.g. 'don't forget to bring your midterm evaluations to this teaching session'. There are many more features, these are the ones I like most. The designers update the app on a fairly regular basis with improvements.

Definitely worth the price tag.
C: $6.99

Toodledo: I love that I can type up my to do list on my computer, organize it into folders depending on what the tasks are and sync it to my iPhone. Then I can tick off everything as I get it done.

I love ticking off that things are done!

Some of the features include setting up a repeating task (e.g. laundry qweekly), entirely customizable folders, lists tasks according to when they are due or by folder, you can add notes to tasks. They've added a notebook feature for the folders but I haven't really taken advantage of that yet. I can see it being useful for putting in contact information for a research project though.

Tasks can be organized into high to low priorities, or even star the ones you simply can't miss doing. The Hotlist automatically fills up with your most important tasks based on how you have organized them.

You can set up reminders with a series of fun sounds.

C: $3.99

File App:
This is a great way to store pdfs and word documents onto your device to save for later. I've filled mine with the lecture slides for this block so I can refer to them during lectures or review during down time. It really is all about being able to keep learning during downtime.

I also have my own versions of 'complete history and physical' sheets in it for 03:00 when I know I'm forgetting something, but can't remember what.

It's easy to set up sharing with your home wifi network so that you have your documents native to the device.

Some documents are just too big (my pdf version of the First Aid series), but it can still hold some large documents (my pdf version of the Case File series). I wouldn't bother getting the pro version since the free is so useful just as it is.

Free!

iFlashcards study helper:
This is another app you sync with your online account to have information native to your device. You can even share your login with someone you study with to enhance your pack of 'flash cards'. It's easy enough to make up the questions you know you'll need to review. I use this app for things like drug doses and uses, hormones, structures in anatomy. You can also put photos in.

When studying, you can mark cards you want to go back to or shuffle the deck and go through the whole thing again. You can also reverse how the cards are presented (i.e. given an answer, what was the question).

C: $3.99

PubMed On Tap:

Exactly what it sounds like. You need an internet connection for this one. By typing in keywords to the search engine, the app gives you a list of abstracts to peruse - the entire abstract. You can save the abstracts you want to look up in a file. If you have a mac you can sync this list with your computer. If there is a free article available, it will connect you with the resource.

I love it.

Even with just the abstract, you can get information on the latest research in whatever question is being discussed. I've used it to find the current guidelines on dosing of meds not commonly used and why paediatricians don't know about Octaplex.

The only real problem with it is a problem with me, my spelling. There is no autocorrect and it will only search for exactly what you put in.

The Lite version only gives you 20 (or 10?) abstracts at a time. I upgraded to this version within a day of using the Lite.

C: $2.99

Dragon Dictation:

This is an indulgent, not always useful app, good for when I'd rather talk out loud than type though. I'm impressed with how well it picks up my voice and converts it to written words.

The latest update adds to the keyboard that was available for editing. Now you can email, text, facebook, copy your dictation for use in another app or on your home computer.

Great for thinking out loud about research papers. It's a program I've seen for computers while at conferences and one that I plan on using in my own practice when I grow up.

Free!

long weekends are also for worms in dirt contests

and getting very very dirty

long weekends are made for napping

Considering dipping my feet in chocolate

Or maybe enrolling in a social niceties class.

I spent yesterday with my foot in my mouth or realising that I am not ever going to be a standoffish doctor.

In the morning, in front of a consultant I went on and on about hating this rotation. In my defence I didn't see him right away because he was behind a nurse in the elevator. Still mortifying. I know him outside of the hospital as well which for some reason makes it even worse.

There was an emergency that didn't follow protocol in a rapid manner. The nurses had been harping on it being someone else's fault. Likely the family medicine resident but they wouldn't listen to me who saw the miscommunication take place. I told our chief resident that a miscommunication that took place was as much the nurse's fault as the resident as the nurse came around the corner.

d'oh

Later in the day, I accidently told a patient's family she'd had a boy when it was supposed to be a surprise. The same patient had an incredibly stressful day. During one of the most stressful moments, I was at her head, stroking her hair and trying to keep her calm. Without thinking, I bent over and kissed her on the forehead. She seemed to need a familiar action. Regretted it immediately. The patient however told me later that she was very happy for it. It made her feel happy and good in the moment.

phew

I am an emotional person. I have always been an emotional person. I speak my mind, I tell people I love them, I get excited when they're excited, I cry when they cry. It makes me get too involved, I worry when others don't.

I think it also makes a difference when people are having a really bad day. That makes the rest of it worth while.

That's a foggy foggy morning

Awesome photo from Cute Overload, nothing to do with what I want to talk about today.

Despite the fact that Canada has "universal health care", not all our patients have access to this care. Women find themselves in a position of needing to choose between affording birth control and paying rent. I met one of these women who ended up pregnant, keeping the child and now has even more financial problems than if she had forgone her rent and bought birth control.

The Mirena IUD, one of the best options for women who are myopic in their health care choices, is the most expensive option at the initial outlay. It costs approximately $400. This is a one time cost and the Mirena lasts for 5 years. There is no need to remember to take pills daily or ensure his love is gloved to prevent a pregnancy. It's also a fabulous way to control heavy periods. The $400 is quite a bit for the woman who can't afford utilities.

Some docs are good enough to keep some of the samples given out by drug reps. This is disturbing on a whole different level. There is something to be said for beggars can't be choosers. If the birth control that may be the best choice for the patient (e.g. a mini pill, the nuva ring, mirena), is not available as a sample, then the patient gets the second (or third, or fourth) best option. Samples are given to the docs as good will from the drug reps to get their foot in the door, but also so that the docs can give them out to the patients who need them and see how they react and learn how the drug works.

New research out of Kingston shows that poverty plays a role in cancer prognosis. I assumed it would be because these folks are less likely to seek medical attention early, but one of the things they found was that patients presented at the same stage in their cancer. While it's true that we have universal health care in this country, we don't have universal access to healthy foods, education about our health and access to health promoting activities. The researchers are looking at "other factors such as tumour biology, presence of other illnesses, access to treatment, quality of care, or differences in nutrition, exercise and smoking may also play a role in survival".

Fat makes the news

A thin woman was kicked off a plane to make room for an obese teenager.

I'm not sure how I feel about this one. I get that airlines have a difficult time with keeping obese and normal weight customers happy. What seems wrong though is that a person can take up 2 seats but pay for one. If the seats were too small to begin with, that's fair, they should give fat folks 2. If not, it seems right that they charge for 2 seats. It's what musicians have to pay to keep their instruments close.

What a political nightmare though.

CaRMS wackiness

When med students in Canada are entering their final year of study, they apply through CaRMS for their residency - the Canadian Residency Matching Service.

To put it mildly, it's a terrifying time for students in the 2011 classes across Canada. Some have been padding their resumes since they got their acceptance to med school oh so many moons ago. Others have just realized that they should have done research/picked a specialty/vaccinated a small country before now and are currently scrambling to fill their CV with astounding accomplishments. It's a bit goofy.

Back in the day, Canada had a brilliant way of doing things. Rather than being forced to choose our specialty right out of clerkship, medical students went into a year of internship. This was spent in a series of departments - like the clerkship year was for me - but with more responsibilities. Following this year, the students matched to their residencies where they focused their studies. Some docs went straight from this year to practice (general practitioner), while specialists specialized.

Problem was that eventually docs wanted to specialize early and did 'straight internships' that set them up for their specialty. Clerkship was developed to give medical trainees a way to see aspects of medicine they may not otherwise have access to. Unfortunately in the short amount of time allocated to students in clerkship per rotation, it is difficult to get a good idea of what the specialty is really all about. For example, my deliver room rotation is only 2 weeks long. We had 1 woman deliver a baby during business hours this week. I couldn't possibly decide I wanted to be an Obstetrician based on that.

This was a problem when the rotating internship year was in practice too, now it's moved forward a year or two.

While I accept that the one year of rotating internship is insufficient to train a modern physician to be able to practice anything, having just one year to choose our future is also insufficient.

At my school we have four months in our last year that is just for electives, a way to pad our CaRMS resume and discover more about the specialty we have chosen to pursue or rule out. My classmates started setting up these fall electives in January to ensure their application to residency would be shiny.

This is a great system for those students who are born knowing precisely what they want to do AND are correct. Some in my class however found out half way through (or later) in their clerkship year that they were not pursuing the path they should. They fell in love with a new specialty and are scrambling at the last minute to get electives and research set up in this new specialty.

I don't have a solution to this aside from starting our residency years split into two camps, medicine and surgery. Set up a rotating year based on this, then apply after our R1 year to the specialty of choice.

first night of call on obs/gyne

First thing my resident said to me... "oh, you're the clerk? I thought you were someone important".

huh

Surprisingly it got much better after that. I helped deliver 5 babies, assisted a c section, a salpinectomy and did 3 crazy consults in the emerg. Fun!

old school

The outpatient obs/gyne clinic is cooled by fans and some in window air conditioners.

Because the patients you want feeling warm are pregnant and menopausal women.

just heading in

Obs/Gyn clinic starts at 1pm. I will not be there early. Not a fan of this rotation.

studying on the beach

yay summer!!

Losing track of the big picture

Something that happens quite frequently, especially in pediatrics is a lack of acknowledgement of the child as a person. This unfortunately also becomes a lack of acknowledgement of the parent as a person.

As a team of consultant, senior and junior residents and medical students, a herd of eye balls moves room to room in the hospital. The herd parks outside the patient's room and talks about the most recent blood work, biopsy results or imaging. They engage in an intellectual discussion about the findings and what they will mean to the patient's prognosis or treatment plan. They enter, usually without knocking and
discuss the plan for the day. Hopefully, this discussion includes the patient and family.

Families are often starved for a sense of being a part of what is happening. They can feel like animals at the zoo. They deserve better.

Medical students often feel like we are bothering the family when we want to ask more questions. There are lots of things that these families can teach us and allowing them to be medical teachers in a teaching hospital allows them to feel less out of control of the situation they are in.

Obviously not every family feels this way. The easiest way to find out is to say something like "hi, I'm the impostor, would you mind if I learn bit more about your child, her illness and what's been going on for your family?". If they have had enough, they will either say no or answer in short terse phrases. Thank them and wish them well.

If however they start to glow and want to tell you everything about the presenting signs of illness and the path taken to get them to your hospital, listen, ask questions and enjoy the experience. I've learned so much from parents.

By the time the child is worked up and on the floor, the reason their parents first brought them in can be lost in the shuffle. Leukemia can first present as sore feet. Cardiac arrhthmias may act like nausea and vomiting.

I've also learned that kids hate a 'pity party'. They want you to ask what sports they play, what video games they have, compliment them on their pajamas. They hate it when we come in, head tilted to the side and with a gentle sigh ask how they are feeling. Treat these kids, especially the cancer kids, like regular kids. They'll tell you if they need something else.

Final lesson, introduce yourself. Telling people your name seems only fair when you know everything about their child. It lets them know you see them as a person rather than just a file.

And frankly, not doing so is just plain rude.

ICU, kind of awesome

Stupid Shozu isn't working again so all my posts from this week haven't shown up.

I've been in the peds icu for my selective. I was really surprised by how few kids have actually been so acutely sick they needed the one on one nursing. It's mostly been a holding pen for the peds floors upstairs.

When acuity does happen, it's exciting. Everyone has their job which they perform well. I was told last week that it wouldn't have mattered if I'd forgotten to pass on that a blood sugar needed to be monitored because "this place runs itself". It's kind of true.

There are many protocols in place to give nurses guidance when orders haven't been written yet. The nurses pretty much run the joint. And
love their job. They have been teaching me all kinds of great stuff like physical findings on kids with congenital disease and why certain feeding protocols are in place.

We start our days by doing handover from the night before, this is done around a table with residents, consultant, nurses and RTs there. Then the residents and I pre-round on our patients. I always get the very well patients so I'm usually done quickly. Then we do xray rounds, looking at the most recent chest films before we round on the patients and potentially change their orders for the day.

Then it's lunch.

The afternoon is spent doing physicals on our patients and writing complete notes and doing teaching if we have a great (read learner
friendly) consultant.

I love ICU, but I think I need more doing and less talking in my days.

looking forward to the weekend

I'm due for some relaxing and kitty snuggling. While I'm loving paediatrics, I really need a little break.

working in scholarship essays

I hate talking about my good points. These scholarship essays expect us to go on about how fabulous we are. The only award I've won so far was nominated by someone else (though I had to give her some pointers). Even then I needed to write my own essay. It's a process that is sometimes discouraging. While I've done quite a bit at my school, I've done very little for the community at large. I simply haven't had time. My thought was I'd take care of my classmates so they could take care of everyone else. Now it seems to be coming back to haunt me.

I sincerely don't think I could spend more time outside of studies involved in activities. I really might blow up. I wonder who will be the people in my class who win all these awards. I hope it gets spread out. My class is fantastic and each deserve an award for something or other.

Please just let me win this one though!

acid base irregularities and anion gaps

It's seems no matter how often I go over the acid-base rules, it seems like it's new every time. There are so many times that I think I need to understand these things so I can care for my patients but seem to just go back to basics to make sure that my gut response is correct. It's amazing to me that we are able to learn so much about our patients' health and metabolism based on anions and cations.

Medicine is so cool.

mmmmm, tastes like summer

after 4 weeks of paediatrics I'm ecstatic to have the weekend off. Not just off, but spending it outside listening to live music and enjoying the weather. And becoming mildly intoxicated.

In the paeds ED, in no paticular order I:
sutured 3 fingers, a lip, a head
saw kid vs. lawnmower
saw what emotional shock can do to the parent of kid vs. lawnmower
fish hook in finger
first presentation of brain cancer
set 2 feet and 2 arms
way too many kids with constipation, gastritis or a cold
one over worked mom who just needed a bit of quiet time and reassurance
several cases of cocksackie
possible child abuse vs. anorexia ?vs. crohn's (that's something for inpatient to sort out)
a kid with a cold whose dad was worried the dying mother might get sick if they visited and wanted permission to go see Mom (heart breaking, especially when they were triaged as not important)
well,sick, happy and sad kids

it's been a good two weeks