The Impostor

I just got my internal medicine evaluation. It's times like these that I feel like I've pulled the wool over everyone's eyes. My preceptor gave me "exceeds expectations" in almost all categories. I know that at more than one point I knew some thing she didn't know, but I really think that was just luck since I've been to so many conferences recently.

Preceptors always say "it may be just because of your background but...." it's their way of turning my older than average status into a positive. This one however was more specific - my experience and that I'm accustomed to working at all. I apparently have a strong work ethic.

When my patients tell me that they think I'm a great doctor, I assume it's just because they like my smile (or, like my little woman from Honduras, because they like my eyes). It's hard to believe that my patients know enough about the intricacies of what is going on behind the scenes to make these statements. That is so incredibly pompous of me to not think that my patients are able to make these assessments.

It's difficult for me to take compliments but maybe it's just as well because I always feel so stupid that I need to study constantly.


- Posted using BlogPress from my iPad

6 months into residency

I didn't realise Christmas was already here. This means I didn't book off my PAIRO sanctioned 5 days. Also that I was not ready for Christmas. We improvised this year with a wire tree.

And yet, I feel relaxed and happy. I seriously am so very lucky to have such a brilliant job.


- Posted using BlogPress from my iPhone

Status quo

Convincing a group to stray from the highway of thought they've always been on can be ridiculously difficult. Ironic when at a meeting discussing leadership but not having people be brave enough to try something new.

At least the breakfast was yummy.




- Posted using BlogPress from my iPhone

No, sorry, I wasn't talking to you

We have been trained in medical school to talk to our patients when taking their histories - not to their family members or friends - whenever possible.

I ask 3 year olds where it hurts, 99 year olds with dementia what is bothering them. Even if your family member is a doctor or x-ray technician, I'd rather hear your story from you. Other people don't mean to, but they end up flavoring your story with their own interpretation of the situation. This can change how I think about your illness which does you no favours. It took me a while to develop any sort of strategy for dealing with friends and families who insist on talking for the patient. I tell them I appreciate their concern but that I really need to hear the information directly from the patient.

Ideally we have translators that are not related to the patient interpret languages we don't understand to avoid this kind of pre-interpretation. When interviewing patients through translation it can be difficult to watch the patient not the translator when the translator is speaking, and to speak directly to the patient. The first few times it feels awkward but eventually it does begin to come more easily.

Twice now I've had patient family members come up to talk to me but I haven't recognized them because I was more focused on my patient than them. I'm very proud of this fact.

Now switch to my friend Wanda who had been living in France. One Sunday morning she woke up feeling funky but not terrible. During brunch she became quite pale and dizzy. Her heart was racing and her husband kindly described her as looking like sh...

They went looking for a doc who took patients on Sunday. The closest was a few blocks away and on the third floor of an apartment building. He was located in the third circle from downtown, definitely should be respectable. His office smelt of cigar smoke, his breath of whiskey. Not surprisingly, Wanda was concerned and wanted to leave, but her husband knew she was sick and made her stay.

When this doc found out that Wanda did not speak French well, he ignored her completely and spoke only with her husband. "does she feel this?" etc. Absolutely awful. Then he grabbed a rocks glass off his shelf, looked in it, and handed it to Nick to have Wanda go pee in it.

After being handed the glass, the doctor stirred the chem strip in the glass, giving Wanda and Nick the impression he was using a swizzle stick and may take a sip at any moment.

Even though this doc made the correct diagnosis and cleared up Wanda's pyelonephritis, he gave the couple the impression that he was not a good physician.

By the way, the reason those family members wanted to talk to me was to tell me that my patient had really enjoyed the care they got and appreciated my advice. I'm hoping that this is something I can internalize and continue to do when my life as a doc gets busier and the temptation to talk to the 65year old daughter of the 85 year old tangential patient gets stronger and stronger.

(sorry if the details aren't perfect Wanda, I'm not used to telling true stories on here!)


Posted using BlogPress from my iPhone

The ever expanding human spirit and jam jars

Something that almost all my non-medical friends ask me at one point or another is what embarrassing things patients have had to confess to me. In particular, things that patients have lodged in their behinds after "accidentally" falling on them.

I can't think of any of my own.

I have seen x-rays of others' cases though.

Most memorable was a jam jar. Not because it was particularly large, but because there is no tapering before a jam jar comes to it's full width.

As one butt curious friend put it, you should never underestimate the ever expanding power of the human spirit to get things done.


- Posted using BlogPress from my iPhone

Deep chart reviews

To save time and help guide our conversations when talking with patients, especially when doing consults, we will often look at old charts online and use previous consult notes.

The idea with doing this is that we will review our findings with our patients and/or their families to ensure that things are up to date. At 3 in the morning though, we sometimes get a bit lazy about making sure that everything we have written in the patient's past medical history is up to date and relevant.

We try to do the right thing by gathering information from multiple sources. We know what we need to be doing to be a good health care providers. I've been lazy and not checked info with patients, I know I'm not the only one. This makes me feel guilty and it should.

Mistakes get propagated when this happens. One patient I admitted had a mistake propagated through 3 years of consults. This patient had "bipolar disorder" in their past medical history, but did not have any psychiatric meds. I dug deeper in the chart and in the consult notes 4 years back I saw that the patient had been given a bipolar hip prosthetic. This is a fake hip with two sides to it, the cup and the ball. It is definitely not someone with an illness that should be treated with lithium or another mood stabilizer. Patients with psychiatric illnesses are treated differently than the general population. It's not something health care providers should be proud of. This was emphasized when my team realized the patient they had been explaining away cardiac symptoms as being caused by bipolar illness rather than following it up.

Another I've seen which has more dire consequences is pulmonary hypertension being changed to simple hypertension. The patient had low to normal blood pressure so the temptation to take him off his anti-hypertensives was strong. Doing this would have increased the pressure to the patient's lungs causing damage to the lung tissue.

Old notes can give us insight into a patient with chronic illness and how they first presented. Understanding our patients' health requires us to do more than skim past consult notes. We need to question those notes and make sure they are accurate. Since there are so many of us contributing to a patient's chart, we need to make sure that we use it as a communication tool. We are telling the next person who reviews the chart what the condition of our patient was at this point, and what we know their past medical history to be.

We also need to remember that these are legal documents and it's up to us to document only things we know to be true. If the history is impossible to obtain from the patient, which unfortunately often happens, we need to acknowledge that the history comes from old charts rather than from the patient.

At 3 in the morning when consults are pouring in it can be hard to remember to be diligent in out charting but our patients' health depends on it.


- Posted using BlogPress from my iPhone

Follow the bouncing ball

Hospitals have paths marked on their floors directing patients to the x-ray department, the exit, waiting rooms etc. These allow us to send the patients without escorts like nurses or porters. It saves the hospital money but allows the nurses to help other patients. It gives the patients some autonomy to get themselves from the ED to imaging. It also leads to them getting lost then feeling goofy for needing to ask for directions.



- Posted using BlogPress from my iPhone

There are no call rooms left!

But that's ok says my preceptor, at least you have the comfy couches.

If this thing is 4 feet long I'll eat my mrsa covered shoe.


- Posted using BlogPress from my iPhone

End of life

The Globe and Mail is doing a fantastic series on end of life care in Canada http://www.theglobeandmail.com/life/health/end-of-life/. If you haven't looked at it yet, I really suggest you do.

Reading it has made me realize how very pessimistic I often am when strangers are in front of me in distress. The section on critical care reminded me that young people who are mentally capable end up on ventilation too. So much of my experience has been with both the elderly and those who have become mentally incompetent due to stroke that I'm forget that anyone else could find themselves in need of a tube down their throat.

That article in particular showed a hopeful future for a few of the patients and families interviewed. I'm sure that after talking with the family and patient I would see the value of ventilation but I hope I would be starting from a place of being able to listen and being open to the family's needs.

Seeing how futile vents often are for patients has already jaded me. I forget that people may have more that they need to tell their family and pets, how important getting to say good bye can be for a family, that people do sometimes get better and that having hope is one of our most precious commodities. At least I'd seemed to have forgotten all that while reading these articles.

My hope is that with the patient in front of me I will continue to have an open mind, to consider what the patient wants and to have hope for a brighter future.


- Posted using BlogPress from my iPad

Hands on experience

I went to the OCFP conference in Toronto this past week were I learned so much. At the end of every day my brain was very full. Very. Fantastic.

One workshop I attended was breast aspiration. Easier than I thought I would be.

On the silicone models at least.


- Posted using BlogPress from my iPhone

It's a public cervix announcement!!

- Posted using BlogPress from my iPhone

My first site visit

Today I went to a community that I'm thinking about working in at the end of residency. It was very soul soothing to picture myself in a small community filling a role. And close to water. And trees. And fields. Swoon.

On the way there I went through Mennonite country.


That was a blast from the past too. Signs for maple syrup and quilts, buggies and smoke houses. This was exactly the kind of invigorating trip I needed.


- Posted using BlogPress from my iPhone

Food at work

What about eating in the hospital when you're working? This depends on whether you're a clerk, resident, nurse or consultant. It also depends on what service you're on.

When I was on the vascular surgery service, I lived on cheese and cookie sandwiches and diet gingerale pilfered from the ED fridge. My senior resident ate power bars between surgeries around lunch time. Eating an actual meal was scoffed at.

On general surgery, my team met for a working lunch to run the pt list and assign tasks. It was an incredibly busy day for all the other teams but our consultants were not in the hospital so our team had been pitching in as we could. One of the consultants from another team "caught us" sitting down to eat and made a snide comment about us being lazy. The comments and judging continued for the entire time I was on service: in rounds, on the floor, in the OR.

As someone who had been thoroughly convinced that general surgery was not for me, I wasn't as shy about speaking my mind. Given my absolute lack of sleep it wasn't my best retort though, something along the lines of being judged for multi tasking by running our list while eating so we didn't collapse in surgery later that afternoon.

The general surgeon residents got very good at finding spots in the hospital and cafeteria where they wouldn't be seen by consultants. That's ridiculous. It breeds a sense of us against them and a feeling that the bare necessities of life aren't important when you're a resident.

I was rather shocked when I went onto the eating disorder service next. Not only was I expected to eat lunch, I was also expected to eat morning and afternoon snacks as well. When I chose to work while eating my lunch I was harshly judged by the team. I got reminders when it was snack time. Wow.

The internal medicine service provided us with coffee every morning, lunch every day and cookies and milk on Friday afternoon. The pharmaceutical companies pay for these treats but we never really know who they are or how much they give. Lunches were done with rounds - line up to get yummy food (not just pizza!) then listen to lectures or take part in group discussions. These lunch hours were important for learning and for connecting with our teams and the residents and clerks on other services. Friday afternoons were EKG rounds with cookies and milk. It's hard to be terrified of not knowing how to read EKGs when you have cookies.

Something I keep being shocked about is that my internal medicine and some of my emergency medicine preceptors make sure that I get a lunch break. They often don't take breaks themselves but want to ensure that we don't continue that habit.

I think what shocks me about getting lunch is that I keep hearing so many docs (to be fair, mostly old school ones) saying that the problem with my generation of doctors is that we won't be working enough. Their fear is that we will not make medicine our whole life like they've done. Maybe that's part of the unexpected advice and push for us to take breaks - they don't want us to make the same mistakes they have.

When it comes right down to it, I don't really care if I get a nice break in the middle of the day. Having the choice to scarf some food down and access to coffee is all I really need. Every now and then I also need a breath of fresh air. Too much of a break makes me lose my momentum. Talking to my fellow residents though, I'm a bit of an anomaly. They want to have a full lunch break in their day.

Having the option to have a meal, snack, break or breath of fresh air is what makes the day go better. As with most folks in life, residents just want a bit of control over the basics of their life.


- Posted using BlogPress from my iPad

I've just called in sick

It's something I really try not to do. It's the second time I've had to do it this week. Sunday, I was barely able to stand, today I look like the revenge of the green monster with snot coming out of my face at the speed of, well, snot.

I know it's not what I'm supposed to do as a resident. I should suck it up and go in to learn. White Coat Black Art devoted part of a program to the idea of resident's feeling a need to go into work sick. We feel like we're looked at as weak and not keen when we need to stay home. We're letting the team down. We aren't learning as much as we could - we have Malcom Gladwell's hours to fulfil after all. We know that this will be the day that the patient with a rupturing AAA and MS with typhoid comes in and we'll miss that fantastic learning experience.

In cases like my current rotation, I just don't even know how to call in sick. I have a different preceptor every day. My rotation is in a different city so I don't know how they do things. When I stayed home sick on Sunday, I still drove in after taking Tylenol hoping that the acetaminophen would make me feel better. By the time I arrived at the hospital though, I was a mess - dizzy, my legs were wobbly and I couldn't stand up right. So I waited to tell my preceptor I was sick then drove the 45 minutes back home again. That's safe.

In general, we get stuck in this culture that really rewards us for showing up to work and putting in a strong effort but also gets upset with us for making other people sick. One of the residents on the WCBA pod cast about going into work sick told a story about how the daughter of one of her patients told the resident that her mother was sick enough, she didn't need to also have whatever illness the resident had and told her to get out of the room. I can't imagine a patient being that bold but I love it.

If my Dad was re-hospitalized with more heart complaints, I wouldn't want a resident as gross and sick as I am right now taking care of him. And that's how I'm trying to not feel guilty about this decision.

It's not working though.

It's still 2 days I'm taking off in a week. I have so much to learn. I look like a wimp. The script of all things that I'm doing wrong keeps running through my mind. I'm not sure if the script is how I judge other people, how I've heard other people be judged or how I imagine they'll judge me.

I'm not able to pay attention to something that is just as important. When I'm dizzy and falling down, I'm not able to learn much anyway. Best to get better and use my spare time once I'm well to study.

The WCBA podcast talked about a need for the change in culture. It's true. One of my residents on general surgery injected himself with an anti-nausea medication so that he could work through his shift with a stomach flu. Our consultant gave him a strong tongue lashing and told him to get home, that our patients are sick enough and don't need a gastroenteritis as well plus the rest of the team is now at risk because he was with us while we rounded. We need more of these docs to stand up and speak their mind.

I can't help but wonder though, if that surgeon had also decided he needed to stay home b/c of a virus, what would happen to his patients booked in for that day? We don't have a call pool like many nursing teams do so we can get another surgeon in on the fly. Especially another general surgeon with a sub specialty like this one. It's not that he is entirely indispensable, but he definitely has patients who are depending on him to be there when he says he will. They have waited for months for surgery and he only has a few operating days/week that he is allowed to use. The pressures he must feel when feeling unwell must be incredible.

Above all else in my future practice, I hope to not be indispensable. If I'm sick, I really don't want to share that with my patients.

Tension

I've been watching old episodes of 24. I'd completely forgotten how intense it got. I keep finding myself turning off the show to leave the room for a few minutes - or longer.

And yet, someone coding in front of me I can handle? Maybe it's just because we didn't get terrorist training in med school.


- Posted using BlogPress from my iPad

Family Food Lore

When I was hospitalized as a teenager, my dad would come to visit me at dinner time. The hospital food they gave me was awful, seriously terrible. Rubberized pork chops, cold mashed potatoes and cooked carrots. There is no food I hate more than cooked carrots. My dad would sit with me and eat my food for me so the nurses wouldn't give me trouble for not eating. He didn't really know how else to show he cared that I was in hospital in the first place.

We would do the same when we visited other sick friends in the hospital. Bring chocolate or cookies and fruit then share them. Our family would bring Christmas dinner to the long term care facility and enjoy food and fun with my grandmother with Alzheimer's.

Families see food as a way to heal and to show we love each other.

We all have stories in our family about food. The chicken soup that grandma makes that can make anyone feel better, the day Uncle Bob started eating again and we all knew he would survive, turkey dinners mean that family is coming over and the house will be filled with love.

It can make things very confusing and difficult when a loved one at the end of life stops eating. We know from our family lore that food means love and health. It can be devastating when families aren't able to provide one of the few comforts that they know how to give.

Families often want to use what many health care providers consider to be extra-ordinary measures to prevent their loved one from starving. This includes tubes from nose to stomach or a tube inserted into the stomach or intestine through the skin which requires surgery. I've spent quite a lot of time explaining to families that at the end of life we don't really care if we are eating. When the family pushes for tubes, I ask them about the food lore in their family. Through that conversation we are able to find other aspects aside from the food that made the interaction loving.

Having my dad with me despite his hatred of hospitals was a huge deal. Singing songs with my cousins was wonderful. The story of the magic soup doesn't need the soup to be told. Memories of Christmas dinners are as much about the conversation and weird dates as the turkey. Holding hands, hugging, kissing and laughing are as much a part of family food lore as the food itself.


- Posted using BlogPress from my iPad

Food in the Emergency Department

In the emergency department, patients wait for hours once they are inside the doors and being seen by nurses and doctors. They need to wait for us to put their tests and imaging together, actually have it done, wait for the results and possibly start again if our differential diagnosis was incorrect the first time.

If a patient is admitted to the hospital, food is ordered for them. Otherwise they are left on their own. Sometimes dietary has extra meals if the patient it was directed to has already made it to the floor. This meal can be used but only if the nurses have the time to make it happen and if the patient advocates for themselves and asks for it.

Even if the stars align and there is food and someone to give it to you, you may be kept npo - nothing by mouth - in case you need to have surgery. The thing with emergency surgery is it can take days to get. It doesn't feel very emergent if it's you who isn't eating. By the time we do all the necessary tests in the ED, get someone from the surgical service to consult and decide if you do indeed need emergent surgery then book the surgery, it can be the better part of a day.

Anesthesia wants to keep your belly empty to make the surgery as safe as possible since it's fairly common for the anesthesia to make you nauseous and they don't want you aspirating vomit. Kind of nice of them really. Very often, towards the end of a day, surgeons and nurses of pts will call the OR and ask if they can "feed the patient".

On the other hand are the patients who are "frequent flyers" in the ED. These include those with chronic illnesses requiring multiple transfusions, sub- optimally managed epilepsy, and my personal favourite, the street folks with substance abuse problems who often pass out and get picked up to ensure they are OK.

An old favourite from clerkship was a woman with a bright orange jacket - always knew it was her. I sincerely enjoyed seeing her. Her drink of choice was listerine because it was cheap and easy to steal. For those that don't know, the listerine drunk is a stinky drunk. She was grumpy but only half-hearted at it. She'd swear at me while I was making sure she hadn't aspirated but wink at me before I left her cubicle. Her sandwich of choice from the patient fridge was chicken salad. If it wasn't there, it was only a very brave person who dared bring a turkey sandwich instead.

It is a little disturbing that so many patients do demand food be given by the department. It seems like a part of the service driven culture that health providers are expected to be a part of. If you were waiting for your car to be fixed, you don't expect a free meal. Often car repair shops have a cafeteria or a vending machine just for this. It's strange that there's an expectation for food and snacks when getting your body checked out.

I can understand the patients there on their own with no source of food otherwise, but I'm grateful for the patients with families who ask if they can eat then go to the cafeteria or Tim Horton's to get something. Hospital food is not good, emergency food even more so.

- Posted using BlogPress from my iPad

Feeding our patients

Food is so engrained in health care but we often don't realize it.

Demented patients often lose their ability to chew and swallow swell. There are too many steps for their damaged neural pathways to figure out - using a knife to cut the food to appropriate size, a fork to bring it to the mouth, chew a sufficient number of times then swallow - don't aspirate.

To make up for this, we give them puréed food. All they need to do is scoop and swallow.

Even this can be difficult. Senile patients often need multiple cueing to keep them on track in getting the food to their mouth. More cueing needs to take place to remind them to swallow. When patients are being fed, we sometimes need to do something called "double spooning" to work the visual clues that remind the patient to swallow.

This puréed food is gross. Everything looks somewhat beige and has the texture of baby food. Even worse, all factors that make the food smell like food are removed. So, we ask our demented patients to eat these trays full of monochromatic piles of mush that look and smell like paste. It's no wonder multiple cueing is needed. These well meaning manufacturers are even able to make french toast unappealing. French toast!! That's just blasphemy.

With dementia often comes depression and a strong drop in appetite. Appetite can often be stimulated by strongly yummy smelling food (why so many grocery stores have in store bakeries!), but this sense is being ignored in our food prep in hospitals.

This is why I'm one of those wacky docs who encourage outside food. McDonalds for the post GI surgery patient who hasn't eaten for 5 days and is nauseated by everything sent up by the kitchen. Homemade perogies for the grandma who just can't seem to kick this pneumonia. Dates for the palliative patient with aspiration issues if it makes him happy and he and his family understand the risk.

Families bringing in their own smelly soups and eating in front of their demented relative. This works two ways - adds the social cue for eating we are lacking in the average hospital room as well as scent the room with deliciousness to fool the patient's palate.

I have a lot to say about food. Expect more soon.


- Posted using BlogPress from my iPad

Racial profiling?

When I see a group of young Asian adults smoking, I want to run up to them and yell "nasopharyngeal carcinoma!!!!"

Those of east Asian and African decent are more likely to develop nasopharyngeal carcinoma, a stinky, awful disease that is not amenable to surgical correction.

I know I'm more sensitive after meeting someone being palliated for the illness. Is it appropriate for me to introduce this kind of information to my patients? Definitely.




But what about strangers? I have a feeling I would sound like a crazy prophet person saying the sky is falling.


- Posted using BlogPress from my iPhone

What I learned at FMF this year

1. Skin to skin contact is important in the first two hours of life.
2. Pastry and coffee makes the world a better place.
3. The finer points of belly dancing and male exploitation.
4. My new iPad has a fantastic battery life.
5. That I still know nothing about obstetrics.
6. The best booths have free chocolate or IUDs to hand out.
7. I will never stay at a hotel without a liquor license again.

- Posted using BlogPress from my iPhone

Locked out of the hotel room.

Can't help but notice the wallpaper looks like robots.


- Posted using BlogPress from my iPhone

Hallowe'en!!

Two for the kiddos... One for me.




-


Posted using BlogPress from my iPhone

Unmet Objectives

Yesterday was my last day in the emergency department. It was a day of mixed feelings.

I didn't feel at home in this ED. They weren't familiar with having learners in the department and tended to make me feel uncomfortable and sometimes unwelcome.

The few preceptors who were enthusiastic to teach were a lot of fun to work with and I appreciated their caring and the cake they provided to say good bye with.

Despite my personal enthusiasm to learn, I only met a few of my many learning objectives. Part of this was from the volume we saw in the ED - I can't practice inserting central lines when there is no need for it. The preceptors were not comfortable with me taking the lead in cases where I could use my ACLS. It may be that they didn't realise that I was certified to help a patient whose heart had stopped.

I did however get very good at diagnosing UTIs, sinus headaches and sciatica as well as suturing almost any body part you can think of.

While I don't want to add an extra year of learning to my residency, I do want to be proficient enough to feel comfortable being the only doc in a small ED. I may need to either add learning through simulations or electives.

I really hope that my Internal Medicine rotation that I start next will be more fruitful.

Ouch.

One reason to not attempt kooky sports without training.


- Posted using BlogPress from my iPhone

Sometimes, I hate my patients

Like, really, really hate them. Want to punch them in the nose, squish their toes with the base of the gyne lamp, tell them they're stupid-dummy-heads, hate them.

I know that there are higher psychological reasons for why I hate them, that there is transference from someone else in my life, countertransferance of someone else in their life, personality disorders, weird smells, ..... It's just that sometimes I really don't care.

It takes quite a bit of effort for me to still treat them well. I find it hard to make my clinical decisions with these patients. Before I choose a test, a treatment or a referral to someone else, I need to check in with my conscious to make sure I'm not basing any choices solely on my hatred for the patient. Is that enema really necessary? Am I trying to ditch this patient into someone else's service so that I don't have to worry about it any more? Emotionally, it takes much more out of me. It also takes more of my time because I'm second guessing why I am making the decisions I am.

Even though I know I'm not the only one who feels this way about patients, it's nice to know that there is evidence to back that up.

I also know that I will spend more time with the patients that I like. This is something that I don't spend as much time thinking about but wonder if I should start. It would be just as wrong for me to not order invasive tests because I like the patient or spend time that should be spent on other activities.

These patients are going to more likely to lie to me to make me like them more. I have a patient who has been fibbing to me since day one because she didn't want to disappoint me. I finally called her out on it and we are going to start a different therapeutic alliance. I hate that it had to come to that. I liked being lied to and feeling like I was the best doctor ever because my patient was doing so well.

I swear, every time I think I have a handle on this whole doctor thing, something new pops up to let me know I've never had any form of competence.

It's Flu shot season!!

The traveling RN team is shooting up the staff. She's a floozy.



- Posted using BlogPress from my iPhone

Apps and PodCasts for CaRMS

It seems like most of the random traffic I get to my blog comes from those looking for info on CaRMS, especially those wondering what will happen if they don't match. This post is for you guys. It's intended for the CaRMS tour, but if I wait until then to post it you won't be able to procrastinate now from writing personal letters.

Pod Casts can be a wonderful way of getting ready to speak with interviewers before you head in. The speakers are using doctor words eloquently and may bring up points that are interesting to you and could inspire a tangential chat between you and your interviewer. They can help you pass the time while waiting outside the interview room and since they require headphones, ensure the other candidates won't freak you out. To be honest, I just had a graphic novel with me that I read while waiting. That kept other candidates far away from me because they figured I was a weirdo.

White Coat Black Art is a fantastic pod cast that often gets at the things that we often think about but rarely talk about, in particular the errors that get made in medicine and how we deal with them and with our patients. These are downloadable from the CBC website or through iTunes.

You can also download the app ReachMD for free. This contains a large selection of pod casts ranging from short 10 minute clips to 3 part lectures that are over an hour long. They have a table of contents based on CME, programming series, specialties (you name it, it's there), Listener's favourites, new programming this week. It's an American radio station on XM satellite but they often have Canadian content experts speaking. This may give you an idea of some of the current topics in the specialty you are applying to that you hadn't thought of yet.

Bump is kind of awesome and fun. It's a way to share data between iPhone users. All I use it for is contacts but it has function for photos, apps, music, calendar and social networks. When you are on tour, you'll be meeting some fantastic people you will want to keep in touch with. Bump lets you share your contact information quickly by bumping your 2 phones together so you can text and meet for a beer after interviews. These are your future colleagues, not your enemies, get to know them. Free app!

Starbucks will be in every city you are applying to. Knowing how to get your coffee in the morning or find a place to chill out the night before will make you a much happier applicant. This app has a mapping feature that will help you find directions to the nearest store and includes valuable information such as hours, if they have wireless, if they're drive through and if they will warm your apple fritter for you. Also free!

There will be times when you are preparing for an interview that you want to know some specific information about the city you are applying to. WolframAlpha is the multi trivia app for you. If you ask about the population of the city in question, it has that info plus graphs on the growth of the city in the past 20 years. It will tell you what is nearby to avoid geographical errors in interviews and allows you to compare to other cities. It also has a scientific calculator, information on weather, people and history, music, words and linguistics, information on the local athletic teams. Everything you could possibly want to know to schmooze with the interviewers. $1.99

You want to have your personal letters and CVs with you at all times on the CaRMS tour. It's likely that at some point you will leave the stack of paper in your car or hotel or at home. Emailing it to yourself is a brilliant idea, but what if you can't get access to the internet in the dungeon the interviews are being held in? Am I the only one who plays out these disaster scenarios in my head? I uploaded all my info to Office2Plus. It lets me keep local files on my phone, create word documents there too while I'm feeling creative and connect with my GoogleDocs Cloud folder. You can keep everything in folders that work best for you. The ability to organize everything and the fact that it mimics my PC make me like this app most of all. The original app is free, but you need to purchase within the app for the kinds of files you are using.

The night before your first interview and your interview at your number one school can be brutal for sleep - relaxation is not going to happen. Still, try Andrew Johnson's Relax. This

is a guided relaxation that can make you feel rested. I love his accent. I used this during clerkship too when I had 20 minutes until handover and didn't get any sleep. It helped keep my going just a little bit longer. There's a free version, not sure about that one, but the one for $2.99 lets you choose if you want to wake up or go to sleep at the end of the relaxation time and has different options for the relaxation itself. If I'm extra wired, I go through the meat of the guide 2x.

xkcd has an app. This will keep your humour high during interviews. These are brilliant comics! omg it's free!

Need to put your life into perspective? FML (f my life) has stories of teenage woe that are rarely worth the curse in the title (free). I prefer TFLN (texts from last night), a series of texts that were sent that likely should not have been, more often than not under the influence of alcohol. This one is $0.99 and infinitely entertaining.

Fat Bias in medicine

It happens all the time. You'll hear comments like slob and stupid associated with obese patients. Surgeons in particular have a reputation for commenting about their patients girth in a less than kind manner. I've heard of one patient who, before her surgery, wrote across her abdomen "no fat jokes". It was written so that it was legible from her feet - no easy feat for a pt in hospital. Clearly this is something she was worried about. And she should be. If we don't like our patients or feel that there is something unpleasant about them, we are less likely to treat them well. It's well documented that our psychiatric patients are less likely to have their routine care up to date compared to their counterparts with no mental health concerns.

I did a quick pubmed search looking for obesity discrimination by health care providers. There is a definite dearth of information on the topic. All I know is what I hear. As a larger than average resident, I don't hear as much as what others might, but what I do hear is concerning. In a perfect world, all patients would be seen as equal, no wackiness based on how a patient looks.

We know that role modelling plays an incredibly important part in every medical student's education. Given that medical students start with a bias, it's even more important that those acting as mentors to their students be aware of how their own prejudices can shape attitudes.

"A total of 76 clinical-level medical students were randomly assigned to interact with a digital, virtual female patient who was visibly either obese or non-obese."

The students looked at the virtually obese patient less often and anticipated poor compliance from her. In general they displayed negative stereotyping towards the obese "patient".

Our world is not entirely dim though. Another study has shown that a brief intervention providing anti-bias teaching about obesity is effective in decreasing these negative stereotypes. I worry though that if it's this easy to change an attitude, will the off handed comment of a consultant cause the patient to change back to their previous biases?

She may be onto something

I'm at a medical education retreat. Our presenter on assessment has just said "our students can't give LPs to all their patients presenting with headache - it's dangerous".

I can't help but wonder though, maybe that would encourage PTs to try Tylenol or advil before coming into the ED.


- Posted using BlogPress from my iPhone

I can't decide

This pattern combo is either awesome or giving me a migraine.


- Posted using BlogPress from my iPhone

My MCCQE blanket

I finished this ages ago and have been using it lots. Here's how it turned out. In case you don't remember, the strategy was study a chapter make a square. There are many squares.








- Posted using BlogPress from my iPhone

Happiness is:

A cool rainy fall day off with a lap full of cat and yarn.


- Posted using BlogPress from my iPhone

Counting the days until my vacation south

Until then, piña coladas with dinner.



- Posted using BlogPress from my iPhone

Skateboarding accidents

Three kiddos in a row came in with skateboarding accidents.

The first was a Justin Bieber wannabe with a surprisingly limited vocabulary. He had a supracondylar fracture. I gave him heck for not wearing a helmet or pads.

The second told me he FOOSH'd. I asked what that meant. He told me his mother said to tell me that. She works with a orthopod. He got heck for not wearing pads and praise for wearing a helmet.

The third kid wasn't wearing a helmet or pads but didn't get heck from me at all. It's because he was watching his friends skateboarding and one of the boards got away, flipped in the air and hit my pt in the head.


- Posted using BlogPress from my iPhone

Things that made me smile on the way to work this morning

1. Cute chip monkey hiding from the rain outside my door


2. A plastic shower cap rolling down the street in the wind. It looked like an urban version of a tumble weed.

3. A venti americano misto, light water.


Posted using BlogPress from my iPhone

Residency:

When even my dreams are about me being exhausted but no one will let me rest. My dream last night included begging families to take care of their own children so I could sleep, trying to negotiate future tasks for an opportunity to lie down in a quiet place and asking kitty to join me for a snuggle.

What happened to those good old running for my life dreams that at least provided variety in my life?


- Posted using BlogPress from my iPhone

Reading is still fun

I'm so glad that I was able to complete med school in Canada. In particular, that I was lucky enough to do so at a time when the schools have a pass/fail system.

It means that this column is completely foreign to me. I have never felt the need to hide in my books for fear that I will fail out of med school. Well, moments of terror the night before exams, but not often enough that my partner would have to consider chinese take out in front of the TV for ten minutes a "date".

While I know it makes things a bit more difficult to distinguish candidates from one another during CaRMS based solely on our ability to complete an exam, it allowed me to take part in many political, social and research based extra curriculars. If I had been so inclined, I could have joined some of the many intramural teams my classmates were part of. By removing the grades from our transcripts, we were allowed to develop as people and future leaders while learning medicine. I'm not sure I would have been able to get more from the classes if I had been forced to spend all spare minutes studying.

Instead I studied what I felt was most relevant or interesting and went back to pick up more as I reviewed for exams, clerkship, electives and the MCCQE. Trying to drink from a fire hose of information has never worked for me. Most details are lost on me this way and I just end up feeling stupid and wet.

There is so much to learn when we decide to pursue medicine; physiology, anatomy, pharmacology, pathology. I think one of the most important things I've learned is how to find the information that I need to help my patients in a timely manner.

This system prepared me well for residency. I still take "sips" of information in my spare time, preparing for rounds or formal teaching, reading up on a case that I've seen that day or will see tomorrow, looking up things that I never really got around to learning in my medical degree. The knowledge sticks because it is quickly applied to real life situations. I don't feel a need to run and hide from my books because they ruined the past four years of my life.

At least this is what I tell myself when I'm reading at 4 in the morning instead of sleeping like a normal human being.

Barium contrast

Meant to be swallowed, not inhaled.


- Posted using BlogPress from my iPhone

My niece is the coolest girl I know

She loves our family and wants to hang out with all of us when we come visit. She wears party dresses almost every day and loves how they swirl around her. But that doesn't stop her from painting, jumping in leaves, climbing trees or being swung by her hands and feet.

She knows that wearing two colours of nail polish is twice as pretty. That her aunts will never believe that she's not ticklish and that we will always love her.

She also thinks that I know how to draw EVERYTHING. I think it helps that she only asks me to draw animals and pancakes.


- Posted using BlogPress from my iPhone

Half day

The school has put together sessions for all the residents. Today, we were given a lecture on legal medical type things that I've heard at least 4 times before. So. I picked up new wool and am working on a new afghan. The weather was just to nice out to stay cooped up.


- Posted using BlogPress from my iPhone

Waiting for our patient to be called into the OR

Until then, relax, watch Stuart Little and pretend I can't hear the nurses sniping behind my back. They clearly hate working on Sundays. That's too bad for them.



- Posted using BlogPress from my iPhone

Framing

Framing is something that happens quite a bit in health care settings.

It's when a patient's story is told by someone other than the patient and that story is somehow distorted.

Brian Goldman used an example of this in his talk I attended. From what I remember, the paramedics believed that the patient was on drugs, nurses thought he had borderline personality disorder. When the doc saw the patient, he believed the patient needed a head CT. This patient died of a head bleed in the CT machine. It could be that he had a personality disorder as well as the brain bleed.

When working in a rural ER, I noticed that a patient had been triaged number 5 - blue. I've never seen the lowest level of triage used before. This patient had been waiting for hours and I wanted to see why.

The nurses who had seen the patient said that it was a waste of ER space, that she just had a little cold and there was no reason to be here. I don't mind seeing kids with colds. When I asked why she and her aunt had come to the hospital, it was that they wanted to know if it was OK for the girl to see her father (dying of cancer) in the hospital or if she would make him ill.

While it's true that this wasn't an emergency, it was worth a visit for immediate help.

Last night, a patient came into the ED with "trauma". He tried to explain to the triage nurse what was happening, but she wasn't able to understand and chalked it up to "he doesn't speak English well". Same thing when he came to Fast Track, the nurse rolled her eyes and didn't understand why he was here.

I went to talk to him and asked him why he had come to hospital. He told me that he had a lot of pressure in one of his toes from trauma 1 and a half weeks ago.

In the past when he had a similar injury he had been told that he needed the pressure taken off to avoid the nail falling off. He had a whole story in his head for how it made sense. Pink finger was stage one, blue was stage 2 and a black finger was stage 3. He was stage one but didn't want to lose his nail.

His expectation for this visit was that his nail would be pierced and the pressure taken off the nail. He was afraid of losing his nail. This information made things make so much more sense and now I had something I could do.

By explaining to him how his body works and explaining how I knew that things were ok, he was happy and no longer worried. He will likely not access the health care system for something like this in the future but I armed him with red flags to show back up for.

This interaction could have easily been unsatisfactory for me and the patient if I had decided he was a drug seeker or a malingerer as he was framed to me. Instead, he left with more knowledge and I got to teach a patient about his body, something I love to do.

I'm hoping I always take the time to FIFE my patients. (Feelings Ideas Function Expectation) It's important to me and lets me sleep at night. Patients need to be heard. I need to listen to provide them the care they need.

Teaching

I thought it would be a good idea to teach clinical skills to the first year med students.


I figure the practice can only help me with my own residency.

Posted using BlogPress from my iPhone

Sick day

I look forward to the day when my immune system is able to fight off the flu all those cute kiddos keep coughing in my face.

At least kitty keeps me company.




- Posted using BlogPress from my iPhone

The word that will make every 3 year old boy laugh

Even if he's so sick he can barely hold his head up....

Bum. There's just something hilarious about a doctor saying bum.


- Posted using BlogPress from my iPhone

My Astute Preceptor

The ED I'm working in has two sides - a true emergency department and a fast track for less acute cases.

I worked in fast track all day today.

When the preceptor switched over from the ED to fast track , he acted upset that I'd been hiding there all day.

"But you should have been working with me, doing all that learning that you like to do by seeing all my patients while I sit on my butt drinking coffee!"

Good to know I'm not the only one who has noticed this method of "teaching".


- Posted using BlogPress from my iPhone

Chief Complaint: abdo pain

Final diagnosis: PTSD

More than just once in a while I'd like the cute little kids who come into the ED to just have a cough.


- Posted using BlogPress from my iPhone

Reason number 652 that rural medicine is more my cup of tea

Continuity. Even if I was working in the ED in small communities I found out what happened after they went home. In this city, I have no idea how my patients do after they leave my care. I don't know if my diagnosis was correct or if I made a mistake. I want to know how things go after the patient leaves the department.


- Posted using BlogPress from my iPhone

What's the radiologist's favourite breakfast food?

The waffle.

I had three patients I was seeing in a row. One had a hurt forearm, one a sore elbow and the third (a child) had a sore ankle.

After listening to their stories I sent all three for x-rays.

When the x-rays came back, I thought, in order, fractured, not fractured and I don't know. I made my call to the preceptor I was working with who agreed on all counts. We treated the first and third patient as though they had fractures and the second as though it was a soft tissue injury (rest, ice, elevation).

Yesterday my preceptor for that shift showed me the radiologist's report. Basically he said that it could possibly be a fracture along the growth plate or a variance on normal. We should make our decision clinically.

Thanks for that illuminating report.


- Posted using BlogPress from my iPhone

My preceptor drank my pop!

I was so thirsty after class this afternoon but didn't have time to get a drink before the ER so I grabbed a pop from the vending machines. He drank half my pop before putting it back in front of me and going back to drinking his own.

If I'm not willing to tell a doc that he is putting his gross germs on my pop, how will I deal with a situation like the drunk surgeon we keep hearing about in ethical discussions.


- Posted using BlogPress from my iPhone

Only half an hour away from the hospital is this

Half an hour away from people talking about unconscious patients as if they aren't right there is this :



Half an hour away from specialists who act as though I'm the biggest idiot they've ever met is this;



It's good to remember that there is a life outside the hospital where I can hike and enjoy fresh air and running water.

Sigh.

Posted using BlogPress from my iPhone

So you're not an orthopaedics resident are you

One of my former residents is now a staff orthopaedic surgeon at my hospital. He invited me to assist with an ankle repair. It was going to be very cool - a posterior approach so we'd see a lot of the anatomy. How could I say no?

While he was dissecting out the nerves and muscles he reviewed anatomy with me.

"and what's this?"
Me: "That's the tendon of the halus longus"
Him: "Right, but how can you tell?"
Me: "Because it's the prettiest structure in the ankle."
Scrub nurse: furrows her brow and says "You're not an orthopaedic resident are you?"

The halus longus is pretty, but tensor fascia latta is much prettier.

I ended up spending my ED shift in the OR. I got traded to the general surgeon to assist on his case after the ankle repairs. It made for a fun day. What a change from being the 3 or 4th learner at the table. So cool.

- Posted using BlogPress from my iPhone

Little old ladies say the darndest things.

Little old lady to the cute paramedic pushing her from triage to the waiting room "did you want to sit on my lap for the ride sweetie?"


- Posted using BlogPress from my iPhone

After

One week later, my patient with the abscess on the back of his leg was into the ED again for something else. He wanted me to show you the after picture. He's very happy with the results. Me too. The holes were made by me to allow drainage. They're healing very well.


- Posted using BlogPress from my iPhone

Geriatric Nurses

More and more Ontario EDs are employing geriatric nurses. They go by different acronyms, but their mandates are all the same - see geriatric patients at risk of coming back to the ED soon, or, even worse, being admitted. Geriatric patients who end up admitted to hospital deteriorate. There's no way around it. The hospital environment doesn't stimulate them enough to keep their minds sharp. They end up staying in bed all day and sleeping more than they should so their muscles atrophy. Even a stay of less than 4 days can have lasting negative effects. The geriatric nurses work like heck with the CCAC workers to keep elderly patients at home.

They do fantastic assessments that can take hours (time that ED docs don't have). These assessments can discover things such as medication concerns that may have led to admission, poor walking shoes, poor nutrition, mood concerns etc. With a bit of polish and increased support in the community, the patients are often able to avoid admission and the dangers that lurk within.

In one community I was working in, an 84 year old man was brought into the ED by ambulance following a fall. The geriatric nurse was ecstatic. This was a farming community where most elderly folks are strong and independent and didn't need the extra attention that a geriatric nurse can give.

She went in to check on the man and asked "how did you fall?".

He said, "Well, I was pulling my 2 seated glider back into the hangar and slipped on a bit of water on the floor".

Crestfallen, the geriatric nurse went back to trolling for patients in the ED. Not every patient in their 80s fits the geriatric profile.

What is the geriatric profile?

It changes between hospitals. In general though, it's a patient who is at risk of not coping alone in the community. This can be because they have many illnesses (comorbities), too many prescriptions (polypharmacy), a history of falling, dementia, poor social supports.

I've met patients in their 90s who I wouldn't have really considered geriatric. They live independently in the community, often helping their neighbours (much younger neighbours) with groceries and chores. They have active social lives and manage their few medications well on their own. When the idea of a retirement home comes up, they laugh and tell you that they are for old people. One woman told me she wouldn't be old until she was 96. Don't know why she picked that age, but it made me giggle.

OMG it's white coat black arts guy!!

So cool. Rubber chicken dinner number one as a doc.

He's much shorter than I expected.

Pearls of wisdom: plan your career from the top down. If your AAA is 3 cm, watch. At 5cm operate. When it's 9cm, panic. Emergency medicine is completely part time. Put your 10 000 hours in to what you love. For him, medicine and writing. Good things happen to those who wait. A Bic pen, swallowed by a kookie patient,removed under anaesthesia by a gastroscope will still write. Medical mistakes are a big problem; docs need to be able to speak freely about them, not made to feel shame. Docs need to make a connection w the elderly and remember that they have a vibrant history: their family members are important too.

Borderline personality disorder pts can be people w head trauma but erroneously framed by co workers.

He has had drug seekers tell him all their trade secrets.

He has slept in for presenting grand rounds. He changed his residency program half way through first year. He took courses on how to write during his residency. He hand wrote his first article and his mother typed it.

He started emergency medicine as a fluke because he could moonlight and write.

He's so my hero. I'm such a nerd.




- Posted using BlogPress from my iPhone

Worst movie ever?

It's possible. The dialogue is hysterically awful.


I love it.

Posted using BlogPress from my iPhone

Quizzy Apps

These are apps that I use when I'm bored of reading, when I'm still asleep and know I need to study something or when I'm passing time waiting for something exciting to happen. Great for those with attention issues like me.

Surgical Pimpapalooza

I love this app. The questions I was asked during surgery are the questions that I'd reviewed with the app the night before. The app has been updated so it's even better now - you can save your favourites to review. Favourites is a funny way to put it. More like the ones I screwed up the first time round.

It includes Basic Science (hematology, wound healing, infection, stats, etc.) and Clinical Science (Gen surg topics including breast and endo, head and neck, vascular, gyne, trauma).

The questions are relevant and worth knowing the answers to, e.g. " Indications for splenectomy in a pt with a splenic injury" " Patients with multiple associated injuries (neuro injuries), unstable or in DIC".

So awesome. So worth...

Price: $5.99

iMCQs in Dermatology

This app makes me feel dumb. Every time I think I know what I'm doing in derm, I mess with this app and learn that I'm wrong. I have so much to learn about derm.

The quizzes are set up according to categories, eczema, general, hair, infections etc. Choose your subjects to review and go to it. You are shown a photo and asked for the diagnosis, etiology or treatment. The app has been updated so that you are shown the correct answer and the rationale. Before the update it just said whether or not you have the right answer. That was just ridiculous. You can also ask for hints so you know what you are looking for in the photo.

This is much better.

Sometimes the photos are a bit tiny on my iPhone but you can expand them. This would be a fantastic app on the iPad.

well worth:

Price: $2.99

(looking up this price, I see that this is a series; physiology, general medicine, general surgery, biochemistry and pain medicine)

Emergency Medicine Secrets

Like other quiz apps, this one is set up according to systems, nontraumatic complaints, decsion making etc. Within each category are subcategories that you can choose from to get review questions.

For example: "What are the causes of abdominal pain that are gastric or duodenal in origin?" " An estimated 10% of cases of abdominal pain seen in the ED are due to gastric or duodenal disease. Gastritis and peptic ulcer disease (PUD; ulcer of the stomach or duodenum resulting from gastric acid) account for most patients with abdominal pain secondary to gastric of duodenal disease. Perforated PUD and gastric volvulus are the two most serious conditions requiring immediate diagnosis and treatment."

Remember when I said I had issues with my attention span? Yikes. These answers are pretty long. And they're for emerg docs - well known for their ADHD.

It's true that they are also well known for being afraid of being sued. Maybe this is a consequence of that.

There are also 100 Top Secrets: e.g. "A foreign body in the airway should be suspected in a child with sudden onset of respiratory symptoms and lack of response to appropriate treatment."

I'm a little indifferent about this app. The reading required is just a little bit less than what I do in my text books but without the handy index. It's an app version of the paper book. Not sure it's worth the

Price: $49.99

Another Post about 9-11

I don't have cable. It's not a moral superiority thing, I just know two things about myself. 1. I have a student budget and can't justify that expenditure every month and 2. I turn into a couch potato when I have an endless choice of programs to watch. Better for the world in general if I don't have it.

The morning the planes hit the towers in NY city, I was at my local bakery, in my PJs, as usual. Bleary eyed, I just wanted coffee. One of my customers from the restaurant looked distraught and said "it's so hard to believe isn't it?", I just numbly nodded. She was right, Tuesday mornings are ridiculously hard to believe.

When I got home and was working on my child development assignment, my friend called to tell me about the attack in NY. She knew I was clueless and needed to be told these things. I'm glad she did so I didn't continue to look like a fool the rest of the day when customers told me about the events.

I worked the lunch shift that day. It was not that busy. I guess people were crowded around the TVs at work watching and ordering in pizza.

At about 1:30, a volunteer from some charity came in looking for donations. She asked for a glass of water. Something seemed wrong. I asked if she was ok and she started to cry. Instinctively we hugged until she was OK to sit down. She told me her brother works in the Trade Centre in NY and she had no idea if he was safe or not. Terrifying. I got her the glass of water, held her hand for a moment or two, murmured the usual "don't paint pictures before you know the truth", and "remember he can't call out right now, he may be safe", then let her be. She was calmer when she left a short while later.

This was one of those "I should be a doctor moments".

The restaurant I was working in was run by a Chilean woman. She was a strong independent refugee from the other September 11. The stories she told me about Pinochet were terrifying. She was identified as a radical because she taught her neighbours how to grow vegetables, eat nutritious food on a shoe string budget and how to cook tasty dinners. She had a house full of children and a husband who lived elsewhere so soldiers assumed she had a gun in the house and abused her in front of her children. I don't see the logic in that, but maybe I'm not crazy enough. With her family and neighbours, she sat in the national soccer stadium and watched as those she loved were murdered in front of her then carried out to a mass grave.

I learned about PTSD and survivor guilt from this woman. She didn't realise she was teaching me these lessons because she didn't know and wouldn't acknowledge, that she was suffering.

When Pinochet died of a heart attack at 91, I was reminded that only the good die young. He had dementia in his last years, didn't stand trial for his crimes. I wonder if he ever knew the damage he caused so many Chileans.

Dude! That ain't right!

Leg abscess skilfully drained and debrided by this resident. The patient told me to take a picture and then gave me permission to share it with you guys.

When you see an abscess like this, giving the patient a week of antibiotics is useless. The lesion needs to be drained and cleaned out or it will never get better.

This guy's friend is a nurse who drew the circle around the redness and threatened him with harm if he didn't go to hospital if it got better. That's a good friend.

Key tip to remember: when your skin turns green, it's not healthy.


- Posted using BlogPress from my iPhone

Dx: Happy Monster

Ok, so it's a normal C-spine CT but doesn't it look like a smiley monster? Or maybe an alien?





- Posted using BlogPress from my iPhone

Last long weekend

I can't believe summer has gone by so quickly! Every fall I make plans for the next summer - more camping and kayaking, more patio times with friends. I think this is the first summer in ages I actually got to keep my promises to myself. Bizarre considering that residency has been ruling my life. I think that I was able to squish in more fun because I made a real effort to have fun when I could.

My good friend is flying in this afternoon. We have a busy two days planned before I head back to the ED - dinner, drinks and games/movies; blueberry pancakes on the patio; hiking the escarpment and a spa afternoon.

Having 4 separate weeks of vacation/year encourages residents to use the time wisely and plan ahead to do something fun and/or relaxing. It's been a long time since I've given myself that luxury. I could really get used to it!


- Posted using BlogPress from my iPhone

Welcome to Emerg

Guy: so I was on this ladder with a chainsaw...
Me: (this can't end well)

10 packages of sutures later...


- Posted using BlogPress from my iPhone

Torchwood

I've been watching this new season of Torchwood. It's amazing. There are so many medical ethical issues that are being raised.

In a nut shell, people live forever so there are not enough resources to keep everyone in hospital. The sick are sent to what are essentially concentration camps. They are treated like things rather than human beings. It is a bit reminiscent of how we treat demented patients. They don't have rights and are spoken over rather than to.

Doctors' responsibilities are focused on dealing with placement of these "dead but not dead" patients.

I spent a large part of today's weekend rounds on politics. Moving patients between areas of the hospital, planning resources for patients to go to when they leave and continue to manage the health of patients who will never leave hospital. We sometimes find ourselves discussing the futility of certain treatments, choosing the course of treatment that is most cost effective. While we always consider what is best for the patient and act accordingly, it often feels that our conversations are centered on economics and politics rather than medicine.

According to the CanMeds roles, resource allocation is an important part of being a doc but it truly is my least favorite part.

I found myself today longing to just figure out a medical problem and make my patients healthier.


- Posted using BlogPress from my iPhone

Diabetes

We measure our diabetic patients' blood sugar using an average estimate called the HbA1c. We like to see this number at around 6 or lower but I often see it much higher.

When I watch a patient's A1c drop it gets me excited. I often proclaim it to be a high five moment. It's a big deal for the patient to make the changes that are needed for them to have their sugars under control.

It's particularly great when my patient is in their nineties and I'm making them give me a high five.

Well. Great for me anyway.


- Posted using BlogPress from my iPhone

A Foot Problem

This story is one from clerkship, one of my ER shifts. It a particularly busy shift. There were several codes, a few traumas and people generally having bad days everywhere.

As a result, the waiting time for less urgent cases was long - some eight hours. I met a patient who was triaged as “green” (not urgent) with a “foot problem”. He did not speak English. His friend spoke some English, but not much. I had a difficult time doing my normal history and physical. It was almost impossible to understand what his past medical history was, when he began to feel unwell or anything else we would normally ask a patient. The patient was perseverating about first his length of stay in the ER then his foot that was causing him problems with walking.

I was frustrated. So incredibly frustrated. I had to keep leaving to check in on my other patients and calm down enough that I could talk to him again. Eventually I realized that this guy was sick. I couldn’t tell if it was a neuro problem (?stroke, trauma, seizure) or a cardiac problem. Once I was able to figure this out - at least one or two hours after laying eyes on the patient - things went much quicker. He had an ECG, cardiac enzymes, blood work up, CT head, everything I could throw at him.

He was indeed unwell. He went for neurosurgery that night.

It’s a good ending - I saw him a month later and he was well, walking and doing his normal life.

This is a story about the system though.

The nurse who triaged my patient didn’t realise that this patient was as sick as he was and took the fact that the patient stated he had a foot problem at face value. They didn’t call a translator and probably wouldn’t have known the patient’s language or where to find a translator in the city.

The nurses who had this patient in their area didn’t check in on him. He was triaged green, he could wait. They had patients with active cardiac issues to tend to. They believed the green triage and had difficulty getting past the language barrier.

Without a proper translator I found the interview process for this patient difficult and annoying. I was focused on the annoyance rather than the illness of the patient. It wasn’t until I chose to go past the history to the physical that his illness became apparent.

Once his neurological deficits were apparent, the nurses were amazing in helping me get tests done quickly. Consults were called in, the patient was cared for.

10 hours after first presenting to the ED.

I was angry with myself and with the system that caused this patient to have such a terrible experience. I felt guilty for being so frustrated with the language barrier I had with this patient. I was scared that because of my ignorance my patient would have lasting deficits.

Rather than be angry with a triaging system that was doing what it could, I looked for practical solutions to the problem. With the immigration hub in town, we came up with a “health passport” for new Canadians. It contains basic info about the patient like their country of origin, mother tongue and how to get in touch with a translator. It would also contain their past medical history, medications and other important medical information that would help the ED physicians.

I left the community before I could see it put into place. I hope it’s being used with good benefit.

Kids say the darndest things

I have an adorable young family who comes into the office. Every time I see them I giggle because mom allows the kids to dress themselves. Sometimes I'm treating princesses other times race car drivers. They are a lot of fun.

Yesterday, Kiddo was in for a sore ear. Every time I tried to look, he'd swivel his head around to look at my stethoscope. Finally I just hung it around his neck so I could do the exam.

While I was telling Mom what I saw, Kiddo put the bell in the middle of my chest and said "ba bum ba bum ba bum". I asked him what noise my stomach made. He said "whooshy wishy woosh". I asked what noise his knee made. He said "sqeeeeeee". Then I went back to th exam but he clearly wasn't done. He said "what sound does you boob make?" put the bell on my breast and said, "woooo-uuu, woooo-uuu".

Mom quickly stuck out her elbow and asked what sound it made.

- Posted using BlogPress from my iPhone

My favorite plan for a patient yet;

More foreplay!!!



I should start to prescribe it more freely.


- Posted using BlogPress from my iPhone

Why do my patients wait until my preceptor goes away to decomponsate??

Why?? I love the learning I get to do when I'm on my own, but the terror of not knowing what to do plus the realization it's up to me to figure out how to keep the patients alive ... It's a lot for a new resident.

My next block is emergency medicine. It's less intense than family right? No? Dammit.


- Posted using BlogPress from my iPhone

Jam

I try to ask my in patients if there's something I can do for them before I leave. Sometimes it's a change to their bowel meds, others something goofy like get me out of here. It's a way for us
to get the little uncomfortable things fixed and sometimes have a giggle. I think it's good patient care. We are always running between patients and trying to get to clinic so the little things are easily missed.

This morning, after thinking very hard about it, one of my elderly patients waiting for placement replied "you know, I'd really like an extra jam for my toast. I love jam and one just isn't enough".

That patient is on a high calorie diet in an attempt to help him gain weight. The jam makes sense from my point of view.

I asked the head nurse if I could order it for him and she said no.

But, as I was leaving, she was on the phone with dietary making the request.

Things like that are good for patients, good for hospital staff. We are showing we care about individuals and by making my notes about the conversations we have and his request for jam, everyone who picks up the chart has a better idea of what kind of a person the patient is.

He's one who likes jam.


- Posted using BlogPress from my iPhone

When our rounds get canceled

Residents play Super Mario Yahtzee!!



- Posted using BlogPress from my iPhone

High tech problem...

Low tech solution.

There was a quick power outage in town yesterday. The computers mounted on the walls, very high up, shut down.

As I turned onto the floor, I saw a nurse on tip toes with a cane in hand trying to turn the computers back on.

Made me giggle.



- Posted using BlogPress from my iPhone

I hate cigarettes

I hate cigarettes. Hate the smoke they make, hate the stink they cause, hate how addictive they are and the diseases that they cause.

Every time I find out that a patient smokes, I ask them “What can I do today to help you quit smoking?”. It shows I care, that I think smoking is a really bad thing and is non confrontational.

Talking with a couple yesterday, I found out that they smoked. They were joking around that she had told her partner that if he continued to smoke with his Crohn’s disease. I told them that there was something to that since smoking causes damage to our smallest blood vessels like the ones in our retinas.

I then pointed to him and said, it’s the reason you guys get erectile dysfunction when you smoke.

Without missing a beat, he responded, "Ok, when I get erectile dysfunction, I'll get my eyes checked."

I almost fell off my chair I was laughing so hard. Not what I had in mind but really funny.

**unlike all my other stories, this is one that I've asked permission from my patient to share this story with you and was given verbal permission so this is a true, unadulterated story!**

Weekend away

After working almost every day since I got my CPSO number I have taken the weekend off to visit friends and family in Calgary.




Bliss.

Posted using BlogPress from my iPhone

Conversations lawyers don't have with their families

Yesterday was our family reunion. I was late because rounds that morning had been particularly exciting.

Using broad strokes, I explained some of what had gone on to make me take 6 hours instead of the usual 1.5.

"and one patient was my own fault - she was an adorable newborn who I just couldn't put down"

My cousin looked at me, horrified. Then she said, "oh crap, when you first said that, I thought you meant like a vet and I couldn't understand why you'd put a cute baby to sleep forever, doctors aren't supposed to do that"


- Posted using BlogPress from my iPhone