Monday, October 31, 2011

Hallowe'en!!

Two for the kiddos... One for me.




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Sunday, October 30, 2011

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.

Saturday, October 29, 2011

Ouch.

One reason to not attempt kooky sports without training.


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Thursday, October 27, 2011

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.

Tuesday, October 25, 2011

It's Flu shot season!!

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



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Monday, October 24, 2011

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.

Sunday, October 23, 2011

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.

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?

Saturday, October 22, 2011

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.


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I can't decide

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


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Friday, October 21, 2011

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.








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Thursday, October 20, 2011

Happiness is:

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


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Wednesday, October 19, 2011

Counting the days until my vacation south

Until then, piƱa coladas with dinner.



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Tuesday, October 18, 2011

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.


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Sunday, October 16, 2011

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.


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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?


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Friday, October 14, 2011

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.

Wednesday, October 12, 2011

Barium contrast

Meant to be swallowed, not inhaled.


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Tuesday, October 11, 2011

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.


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Wednesday, October 5, 2011

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.


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Sunday, October 2, 2011

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.



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Saturday, October 1, 2011

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.