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.


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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.


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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.


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It's a public cervix announcement!!

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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.


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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.


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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.


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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.


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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.

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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.


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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.


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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.

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Locked out of the hotel room.

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


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