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.

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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.




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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.


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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".


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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.


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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.


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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.


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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.


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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.

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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.

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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?"


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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.


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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.




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Worst movie ever?

It's possible. The dialogue is hysterically awful.


I love it.

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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.


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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?





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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!


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Welcome to Emerg

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

10 packages of sutures later...


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