Ornge crash

This is devastating and hits close to home. We thankfully rarely need the services from Ornge, but when we do, things are already going south. They are a fabulous team that make a huge difference, if only to my piece of mind. I can't imagine how the rest of the Ornge team, the receiving hospital and the patient they were flying to carry feel.


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Waiting on exam results is painful

"The mountains of madness have many little plateaux of sanity" - Terry Pratchett, The Truth.

Our exam began May 3. We should expect results by mid June. MID JUNE. ARE YOU EFFING KIDDING ME.?????

I swear I'm having more, and scarier, nightmares now that I've written. All I can do is rethink everything I did during those three days. I'll see a patient with chronic renal disease and remember a test that I ALWAYS do but forgot to mention. Or, I'll see someone who reminds me of the fake patients in the SOOs and almost burst out crying. Unreal.

If, as my mommy thinks, I passed, at least this will be the last round of exams.

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Residency blues. Again.

I'm lucky enough to not have lost any colleagues to suicide...yet. In the US, physicians are the profession with the highest rate of suicide. Pamela Wible has described three scenarios that I know have at least flitted past my consciousness. The idea that we are supposed to take on as much responsibility as we do and not be allowed to address our own distress is appalling. We shouldn't be afraid to ask for help for fear of losing malpractice insurance.

I know I've blathered on about the stress associated with residency, but honestly feel that I just can't do it enough justice. The words to describe the emotional roller coaster just don't exist. Instead, I'll give you a list of events that I have experienced, usually many in the same day.

Received lab results back that confirm invasive breast cancer in my neighbour.
Been so overwhelmed at work I haven't cleaned my poor kitty's box in well over a week.
Delivered a beautiful baby girl to a mom and dad who couldn't stop kissing each other or the baby to let me congratulate them.
Delivered a beautiful baby boy to a mom who because of her own brain injury will not be allowed to keep him.
Revive a patient during a code blue and have him go on to living a healthy happy life.
Help a young woman suffering from a painful cancer sleep away her last week of life. And then help her parents cope with their daughter's decision.
Lost track of so many emails and Facebook messages from friends I'm surprised they still answer me when I do send a note.
Been told that I'm an incompetent physician who needs to do at least 6 months of remedial training.
Been told I'm a brilliant physician and that my preceptor is excited to have me as a future colleague.
Had patients hug me for telling them about their cancer, their lack of cancer, that I'm leaving a practice, that their mom just died.
Newborn baby exams. Smelling newborn babies.
Helping moms learn to breast feed when they've given up hope.
Missed my nephews special events for work.
Finding my own worrisome lumps.
Had my vacation time continually denied until I just gave up and have weeks of vacation at the end of each residency year left over.

The ups and downs never end. It can be absolutely exhausting. My blog has provided me with some outlet for what I'm doing. I also have a fabulous partner who is extra supportive and a BFF who is going through the same crap. But even with all of the help, residency is incredibly isolating.

This doesn't make sense to me.

Residency is supposed to be preparing us for practice. We should be learning the coping mechanisms now that will keep us from planning a 03:00 dive off a bridge.

Which I suppose leads to the question, what prevents us from becoming hopeless? How do we keep our light shining when we barely have the energy to wash our hair?

Zakari Tatasuggests monthly counselling sessions for residents to address the extra stress that residency incurs. She also says "The idea is not to find a perfect solution but to openly discuss and accept that physicians are vulnerable. The current culture that presents physicians as always being in control of their psychological health should be discarded."

I know an attempt was made in my med school to encourage self care, but it wasn't given as much attention as the importance of knowing how to write a clinical note or avoiding embarrassing the school. Lip service from the chosen few lovey dovey types that isn't also reflected in regular practice is soon lost.

Next week is resident wellness day at my institute. Events will be held in a city I try to visit and will include a speech and yoga. One day a year doing something I could do at home by watching a Ted talk while stretching.

As with most other behaviours, I argue that we need to learn and be taught by example. After breaking bad news, do a debrief and check in on one another. A preceptor who is willing to admit to difficulty dealing with everything on their plate and going through the options of dealing with said overflowing plate teaches a valuable lesson. We are trained to recognize depression and anxiety in our patients but rarely ask our colleagues about it. I've seen a doc whom all his colleagues stated was burned out but none were willing to talk to him or ask how to help him slow down and recharge. The lesson I learned is that my own mental health doesn't matter in my profession.

That can't be right.



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Making patients responsible for their own health

Something we talk about a lot at our hospital is that we expect our patients to take control of their own health.

You're out of breath and coughing like crazy? You should choose to stop smoking.

You've had a headache for three weeks and haven't tried Advil yet? Seriously? I have no words for you.

There are ads everywhere reminding patients that they need to be screened for various cancers. Patients should take responsibility for initiating contact.

Once you make contact, Advil didn't work or want to quit smoking? I'd LOVE to help. But honestly, if I'm pulling you by your nose to take care of yourself, you're not going to like it and I'm going to lose interest. Patients who come in wanting to find out what they can do to prevent constipation or to lower their cholesterol make me glow. I love teaching my patients.

An issue that comes up, as it does with so many patient centred practices, is time.

I try to get around this by building up an idea then giving my patients homework. Next visit, we review what happened. Getting patients to buy in is sometimes tricky but I find it gives us a goal to work towards in our visits, especially those with chronic disease.

I wonder if preparing a journal for patients with a specific disease to work through might work better. This article suggests journaling to improve compliance for exercise in the depressed, and offers suggestions for topics after walks such as "how do the trees around you look?" Maybe having a set list of mini goals to achieve would improve compliance.


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Youngman's Death

Where has this poem been all my life??
Now that I know Roger McGough exists my life means so much more.
Let Me Die A Youngman's Death

Let me die a youngman's death
not a clean and inbetween
the sheets holywater death
not a famous-last-words
peaceful out of breath death
When I'm 73
and in constant good tumour
may I be mown down at dawn
by a bright red sports car
on my way home
from an allnight party
Or when I'm 91
with silver hair
and sitting in a barber's chair
may rival gangsters
with hamfisted tommyguns burst in
and give me a short back and insides
Or when I'm 104
and banned from the Cavern
may my mistress
catching me in bed with her daughter
and fearing for her son
cut me up into little pieces
and throw away every piece but one
Let me die a youngman's death
not a free from sin tiptoe in
candle wax and waning death
not a curtains drawn by angels borne
'what a nice way to go' death 

Roger McGough

All of Life's Important Lessons

Everything you need to know comes from the movie Princess Bride.

Here, Buzzfeed shows us some of the funnier lessons.

A mom blogs about what Princess Bride taught her about autism. I love her take on it and think it's applicable to everyone, not just those who love someone with autism.

My favourite lesson is the first:

1.  Affection doesn’t have to mean saying I love you

Reading a story to someone who’s sick in bed, saying “as you wish” or playing rhyming games that annoy your boss... there are many more ways to show love than just those three little words.

I've found a new reason why this is important. Many patients that I have are stubborn. Shocking I'm sure. Today I told a woman that because she refuses her daughters' help, it's like she's not letting them show her how much they love her.

I may have just taken the guilt trip to a whole new level.

Med Students are Biased Against Obese Patients

I want to pull out the original study, but from this article it looks fairly well done.

Essentially, 3rd year medical students in North Carolina were shown drawings of a thin or obese person and the time to associate positive traits was measured. 1/3 were moderately to severely biased against the obese diagram.

This isn't shocking - we've seen it before with practicing docs.

When planning my education objectives in residency, I often hear warnings about recognizing that there are things I know I don't know, things I know I know, things I don't know I already know and things I don't know that I know

Something I like here is that they point out that we need to find a way for students to be aware of their bias. This is a tricky thing to teach since it often falls into the category "what we don't know we don't know".

Teaching students to recognize bias must be a lot like doing psycho therapy - challenging the thoughts that go on behind our actions. It may be that teachers acknowledging their own biases during case presentation may make it second nature for students to include acknowledging bias in their own work. Providing a positive role model to med students is important. We know that clerks are sponges for behaviours they see on the ward. It seems reasonable that positive behaviours can be picked up this way as well. Possibly, we need to devote class time to learning about distorted thinking. We discuss the biases which are inherent in most medical research but often miss the bias we bring to our everyday life.

"If doctors assume obese patients are lazy or lack willpower, they will be less likely to spend time counseling patients about lifestyle changes they could make," he said. "Doctors also may be less likely to recommend formal weight loss programs if they assume their patient is unlikely to follow through. "

Miller said bias might also make doctors less effective. "If a patient senses his or her doctor doesn't like them or doesn't respect them," he said, "that will damage the trust that is key to an effective patient-physician relationship."

This is an issue for more than just obesity. We see this in substance abuse and alcoholism as well. If we don't ask, don't offer help for change, we are cheating our patients.

More importantly, if we allow our biases to lead us, we are teaching the next generation of docs to do the same.
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Suicidal Ideation

We are taught to screen for patients who want to kill themselves. Mnemonics such as SAD PERSONS offer us structure for listing risk factors that put us on high alert.


Often I hear things like "what's the point in taking my medication when it's only prolonging the inevitable?", or "I'd rather have hair than live the extra year that chemo will buy me." We call this passive suicidal ideation. People who do not plan to kill themselves but wouldn't mind if they were dead.


Shocking to me today, was the patient who calmly told me his plan for suicide. He has spent months researching a clean, pleasant way to die which he believes will not scar his family. He has even invited his brother to sit with him as he goes. This is a man who may not have long to live and wants to leave the world on his own terms, in the manliest way possible. Being eaten alive by wild animals would be preferable to the slow death his COPD promises.


More shocking to me, was the way I dealt with this news. I didn't miss a beat and continued to ask him to explore the idea.


Now that his plan is in the open, psychiatry needs to be involved to prevent him from preemptively taking his own life. I find myself questioning the futility of that, but will honor my oath and do all I can to keep my patient comfortable and alive as long as I can.


The psychiatrist may lift the Form One because the patient is reasonable.


In the mean time, I'm researching how to get an angry grizzly bear into the Resp unit with no one noticing.
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The patients you think about

Have a look at this article. I've been following the blog on twitter and learning quite a bit. This case in particular raised my shackles a bit.

Similar aged woman presents late at night to my ED with a week of deep, dull chest pain. No risk factors. Her ECG was beautiful. D-dimer was negative. OE viral URTI. No improvement with ibuprofen. I was reassured and sent her home to follow up with her family doc ASAP.

Even now, seems reasonable.

I recognize though that I'm someone who suffers from "Nah, it can't be." I know in this case I did all the investigations I would have done for a 45 year old except calling radiology to get a CXR.

Having cases like the one described in the ECG teaching help me to keep perspective. I think we need to share. These odd cases so we remember that not everything we learned in med school was true.

The trick, as ever, is protecting patient privacy while expanding the knowledge base we have available.
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This is NOT a 2 am consult

I'm always afraid of being wrong and making a stupid mistake in front of colleagues. I think it's fairly common, we all want to be seen as competent care givers. We never want to admit that we don't something but when our patients need us to 'fess up about our lack of knowledge, we will, and call a friend.

Working in a small ER means that rather than having in house specialists I can bounce questions off of in the middle of the night, all my specialists are elsewhere in hospitals where they are expected to be allowed to sleep from 11pm on because they'll be on call all weekend. It takes a lot of guts to call after midnight.

I'm sure you can see where this is going.

I've seen a lot, but I haven't come close to seeing everything. I try to extrapolate from what I do know to what I'm seeing in front of me. Given what I saw the other night, and what I know from other similar structures, I was going to need help. Apparently I should have known better and that I didn't need help.

I still feel like I did the right thing. I had a patient in front of me with unbearable pain. The resources in front of me where not at all helpful, though I could have looked for the procedure on youtube... I called. I got snarked at. I also got the info I needed and my patient left free of pain.

Since this blog is about making me a better a doctor, what would I do differently next time?
1. look in even more basic books than I was, something like Tintanelli's.
2. YouTube the procedure.
3. Start my consult (if I still decide to call) with "I'm not sure this is a 2am consult, but my pt is in quite a bit of pain...".
4. Take a breath and put everything in context. I frequently let my nurses guide my care. I trust them to know what to do and very often, that's a good call. But sometimes, I need to listen to my own brain and cut them out.
5. Work out how I would do what I need to do - get the patient into position, get the equipment I need in position. There's something about going through the steps first that makes a procedure easier to do and less scary as well.

Eeyore

I convinced a 5 year old girl this week that Eeyore isn't sad, he's dysthymic. Hearing a wee girl without front teeth say "dysthymic" is awesome.


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Cards Against Humanity

Today was the first of three days of my family medicine licensing exam. It was the short answer management problem day, 3 hours in the morning, 3 hours in the afternoon with an hour for lunch in between.

I had room in my bag for either my notes or my box of cards against humanity game.

I made the right choice.

Playing a silly, irreverent and occasionally dirty game was the perfect mid exam break.


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