Pop Wuj Clinic

Here I am, back from my first shift as a doctor in Guatemala!

I had a ton of fun working in the Pop Wuj Clinic. I got to do what I love -- medicine somewhere totally new. All the staff (ie- med student volunteers, a guatemalan doc and one nurse) were super friendly. I have to say, though, the gem of the experience yesterday was the patients.

These are people from a wide cross-section of guatemalan life. I had a 24 year old woman who hasn´t had a menstrual period in a year and is desperately trying to find out why however she can´t afford the neccessary lab tests.

An 11-year-old boy who looked about 8 was brought in by his school teacher for concern of malnutrition. The school was concerned and had been saving for 2 weeks to have enough money to pay the 20Q ($2.50) fee to be seen in the clinic. His family did not know the school was bringing him.

An affluent woman who refused to take the free meds from the clinic -- she said to keep them for those who need them. She would buy hers at the pharmacy if I would write down what she needed.

My favorite patient of the day was my last. At the end of the morning a single couple still sat in the waiting room -- an old woman in tradition al Mayan dress accompanied by a younger woman in a T-shirt and Jeans. It would be difficult to exemplify the changes Guatemala has undergone in just 1 generation better than these two did.

My patient was the old woman. She was weatherbeaten and deeply tanned with dry, leathery skin. Her face was beautiful -- wrinkled and wide open with bright, laughing eyes and a constant smile. As soon as I call her into the exam room, she smiles, hugs me and kisses my cheek. She is tiny -- barely 4´6" and was wearing the traditional layers upon layers of brightly colored mayan dress and her hair was in long pigtail brains with ribbons hanging down her back. She should have been on the cover of a National Geographic.

Despite the differences in their appearance, the woman and her daughter were the same. Smiley, laughing, open people with significant caring for each other and those around them. They were a pleasure to muddle though my spanish with.

Fortunately her complaints were simple -- I diagnosed her with arthritis and a corneal abrasion. Ibuprofen, eye drops and out the door. I asked her to return in 2 weeks for a check of her eye -- I look forward to seeing her again. Her memory is one of guatemala I will cherish always. My beautiful laughing mayan grandmother.

http://www.pop-wuj.org/medical-spanish/medical-spanish.html#PopWujMedicalClinic

Destination: guatemala

Hi all! (or no one considering how long it has been since my last post)...

I decided that it was time to re-visit this whole blog concept. Lots of things happening in my life. Getting married, becoming a senior resident (scary!) and currently spending a month working in a clinic in beautiful Guatemala.

At the last minute in a five-week rush I managed to arrange an away elective at a medical clinic in the city of Quetzaltenango (Xela). The clinic is located at a spanish language school called Pop-Wuj. Xela is a city located in the mountains of Guatemala about 4 hours by bus from Guatemala City.

In fact, let´s start there. THE BUS. My introduction to life in Guatemala. A smoke-belching old-style greyhound. Comfortable enough to sleep on, yes? ... until you put it onto a guatemalan mountain. And give it a driver who doesn`t like to shift gears. As we went careening up sides of mountains and down into valleys around classic 180-degree turns there was no sleeping, just lots of falling over. On the few and far between straightaways rather than shift up and then down again, the drive just ploughs ahead and the whole bus shakes. Not a little tremor. You know that dance move where you shake your shoulders so your boobs fly back and forth? The boobs, they were a flyin´. Halfway through the trip I also discovered that the seat part of my seat was not attached to the back part. Added entertainment. However, we got to Xela in 3 hours instead of 4.5, so no overall complaints.

The bus ride was also amazingly beautiful - driving through little town and small cities, up into the clouds and then back out again. Women walking along the side of the road in brightly colored mayan dress. All beautiful.

Xela itself is a city known as the cultural capital of guatemala. There are literally innumerable spanish schools here as well as the two largest Guatemalan universities. Overall, the people who live here are very well off- no chickens or goats in the yard, cars, electicity, hot water, extra rooms in their houses to put up visiting spanish students such as myself. There is even a Wal Mart here in Xela (more evidence of america poisonning the world).

I am staying with a family which is... interesting. We`ll leave it at that for now. They are very nice and have been nothing but extremely hospitibal. The matriarch of this three-generation family was quietly waiting for me in the kitchen upon my arrival and promptly sat me down for a meal of rice, beans and tortialls. She also immediately noticed that I don`t like beans when I barely touched my half-plate full. Since my arrival the bean portions got smaller and smaller to the point where she doesn`t even put them on my plate anymore. Smart grandma :-). In fact, most of the time I interact with my host family is with grandma over meals in the kitchen.

Pop Wuj itself is a very interesting place. Currently it is overrun by medical students between their first and second years of medical school looking to get some clinical experience as well as improve their spanish. Other than the hired doctors (2), I am the only physician here. As a result, I was instantly asked "can you cover the clinic on Friday?" I have my army of medical students to oversee.

Pop Wuj as a school firmly believes in community service in all different forms in addition to learning spanish. In fact, all of us "newbies" have been in Cultural Competency class all week where we have been recieving lecures about guatemalan history, philosophy, mayan mysticism and traditional medicines from an AMAZING anthropology professor from one of the Universities. These are the kinds of phenomenal lecutres I wish I had in undergrad -- and they are all in spanish! With a little fuddling through and help from each other, the entire class is able to understand lecutres which jump from spirituality to quantum physics to botany all within a few minutes.

Tomorrow morning is my first shift in the clinic (as supervising physician, no less), so more on that at another time. For now, good bye!

http://www.pop-wuj.org/

Delivering babies

Let's see... what is going on in my life since last time I wrote?... I did a month of Toxicology at Bellevue hospital which was fascinating as always. I did two weeks in the Columbia ER where I got pretty effectively bitch-slapped once or twice (can always count on Columbia for that) and I caught babies for 2 weeks up at the Allen Hospital (Inwood) on Labor and Delivery. Basically, life has been good.

I wish I could regail you with "The tales of labor and delivery!" I basically walked away from my time on L&D thinking "wow, what a wasted, boring two weeks! I saw about 2 patients a day!" However, upon further reflection, I realized that I saw some very important things.

An eclamptic mother in status epilepticus seizing uncontrollably all the way to the operating room to emergently c-section her baby. She has since been in and out of the ICU twice for further complications of eclampsia.

A woman who I now have the highest respect for who did the entirety of labor and delivery without ANY pain control (and let me tell you, it was NOT an easy delivery by any means even if she would have had pain control). I'm actually not entirely sure if she deserves an award or a brisk shaking and an exclamation of "why in the world did you DO that?"

There was the "day of post-partum hemorrhage" where it seemed that every patient was bleeding uncontrollably after delivery (I got very good at calling for HemeAbate). Those are interesting. Looks like a faucet running red water.

Then there was my last day on L&D. I had a 23-week patient who presented in active preterm labor. There was no way to stop the process. The issue is this: there is a 50/50 chance of survival with all of the modern NICU technologies possibly available if a baby is born at 24 weeks. Younger than 23 weeks, there is no chance. 23 weeks is the grey zone. 10% chance of survival, only 5% chance of survival neurologically intact. As we laid the facts out for a distraught couple whose primary language was not english (we used a spanish interpreter for ALL conversations), the emotional stress began to completely block their ability to understand the situation.

Finally, they were able to make a decision, to rationalize SOMETHING out of the entire situation. The attending who had been explaining for an hour that the two options were to a) deliver the baby and provide warmth until the baby passes away in a few minutes or b) delivery the baby and intubate the baby and do everything humanly possible for a long-shot of survival. Finally the father looks at the attending and says "we want an abortion."

HUH?? Abortion wasn't even an option. The word abortion was never even SAID and yet, this was how they were able to rationalize their desire not to have the potential of having a severely disabled child for the rest of their lives (assuming best case scenario). Our jaws dropped and there was silence where we didn't know how this leap had been made. Then the husband went on to ask for us to just take our instruments and tools and go inside and take the baby out. We went through all of it again... explicitly. Mom was going to have to push the baby out. It was a delivery. She was in labor. We were NOT going to go in and take the baby out, it was coming out on its own. The family agreed to let the baby be born and pass away. No heroic measures.

An hour later we are called into the room. It's almost time. There is a new person there -- an extended family member who is fluent in english. She turns to us and demands, "What are the options? Why are they telling me that they are getting and abortion?" If I ever felt like smacking my own forehead, THIS would be the moment. The attending, however, handled the situation with grace by simply stating, "The matter is closed. We have discussed it extensively with the parents and we have agreed to let the baby pass away after it has been born. This is NOT an abortion. This is early labor." We got the interpreter again and went through it again with the parents. Their faces showed complete confusion. But then it was too late for more discussion -- the baby needed to be delivered.

I delivered at 1lb baby boy. He made a single cry and then had no further respirations. He did not move. The room was full of crying, wailing family members. They named the baby, held him, cried and screamed his name, took photos. After all the technical aspects of the delivery were completed and condolences were given, I left. I've never dealt well with rooms full of crying people. I'm a sympathy crier -- not a good trait as a physician. After the parents said goodbye, the baby was taken to the Neonatal ICU and finally pronounced as deceased 3 hours later. I filled out a birth certificate. The pediatrician filled out a death certificate and the matter was closed.

I don't know how those parents will eventually think of the events of the birth and death of their first child. Will they realize what happened -- early, preterm labor -- or will they always rationalize as somehow "choosing" an abortion at 23 weeks? If they rationalize the latter option, how many more pregnancies will they loose because they are passing on incorrect information to future physicians who may be at a different hospital and therefore not have access to our records? It is a terrible dilemma, the stress response of the human psyche.

People Watching

Something that I enjoy as a NYC resident is the so-called pastime of "people watching." Fortunately, Rob is also a world-class people-watcher and the two of us can go to a park or sit in outside at a restaurant or starbucks quietly and completely comfortable with each other watching the world go by. Occasional comments pass such as "awwww" or giggles and most often, "did you see that??"

I, however, also tend to go on a people-watching tangent. It's called dog-watching. Yes, I watch all the NYC pups go by. Take my walk this afternoon before sitting down to write this post. I was walking through a local park near our apartment and fell into my "dog-watching" routine. There was the adorable Great Dane puppy in the dog run who just didn't seem to understand play with non-litter mates yet. The Golden who, upon realizing that they were near the dog park suddenly jumped to the end of its leash to drag its owner to the run.

There was the gay couple riding their bikes on a beautiful summer afternoon -- each with a tiny chihuahua strapped to his chest. (tiny yippy chihuahuas) ... then I passed a couple carrying their CAT on a leash... kitty did NOT look happy.

One of my favorites is a woman in our neighborhood who owns two HUGE and overweight bulldogs who can barely make it around the block in the august heat. She spends most of her time futilely pulling at the leashes, then coaxing and finally tempting inch by inch with doggy treats.

The point is, new yorkers are a great bunch with hillarious dogs.

Funny stuff

So, recently I have a had a number of truly fabulous ER quotes. I thought I would share some of them... some may be funny, some may not...

"well, we come here 'cuz you got doctors good here, yo." Patient's primary language: English.

"Why are you putting in a breathing tube? He fell and his pinky hurts."
-- family of a stridorous patient being intubated for respiratory distress.

me: "are you pregnant?"
patient: "no..."
"you're pregnancy test is positive."
"I'm on birth control!"
"well, amazing things ARE happening here."
"huh?"
"Pee in the cup again."

"well, the blood transfusion raised your hemoglobin from 3 to 6."
"great! so you don't need to admit me anymore?""no..."
"so, one more unit and it will double again and then I'm ok?"
"uh, no. It doesn't really work like that. You're still bleeding. Which is generally considered bad."

"Why do I need surgery? It's just a stab wound."
"You cut the artery. That's why the blood was pumping out."
"so, you can't just give me stitches?"
"no."
"fuck."
Charge nurse: "here's your cell phone. call your mother." (patient's scowls, charge nurse raises an eyebrow and shakes the phone, patient takes phone)

In Remembrance

It has been forever since I last wrote in the blog. Many things have happened -- work, birthdays, vacations, fun times... and I plan to write about all of those, but this post is about something else.

This post is about a being very special to me -- Oscar, one of my family's cats. Born in late 1998, my family adopted Oscar and his brother, Felix from the North Shore Animal League in early 1999 and he was always a wonderful kitty. Being in high school at the time, Oscar and Felix were the first pets my family owned who were pretty solely "my" responsibility -- they lived in my room, their food, water and kitty litter were in my room and I cared for them (and dealt with them waking me at 4:30 in the morning with the now-infamous "double-pounce").

Oscar was instantly dubbed the "purr-box" or "motorboat" for his loud purr heard across the room and incessant demands for attention. Always more outgoing than his brother Felix, he was also the "smart" one of the pair (we missed on the odd couple naming).

Recently, Oscar's health had been deteriorating... he required multiple surgeries to repair problems with his colon. His kidneys were starting to fail. He was loosing weight. 6 months ago a vet recommended we put his to sleep. At that time, my family declined -- he was still running around, purring and head-butting everything as always.


A few days ago my parents called me to see Oscar -- his health had taken a turn for the worse and the decision was made that it was time to let him go. We all miss him sorely -- especially his brother, Felix, but we are all getting through. And so, I raise my glass and drink in remembrance of one fine kitty.

On Restraint (or Lack Thereof)

I'm sick.
For the 3rd time in the last month.
It hasn't been a good month in that respect.

So, I'm feely crappy. I sleep, drag myself to the shower and then decide "you know what? I'm going to lie of the couch and listen to some relaxing music." I sifted through my iPod and picked 1) August's Rhapsody from August Rush, 2) Massenet's Meditation from Thais and 3) Ravel's ballet, Daphnis and Chloe.

The Daphnis is actually what spurned this post. Maybe it's just because I was lying with my eyes closed the only task on my mind to listen to the music or maybe it was because I had a headache and had therefore tweaked the settings on my stereo to turn to volume down and flatten the dynamic range so the louds were softer and the softs louder... I don't know. What I do know is that the Daphnis just sounded so controlled -- too much in control.

A few years ago I had the opportunity to hear one of my favorite pieces, Stravinsky's Rite of Spring, played by first a professional orchestra and then the Julliard Symphony in the same month. The Rite is an incredibly challenging piece and is seldom performed by professional orchestras. It is much more common as a graduate orchestra piece -- something for the soon-to-be professional musicians to sink their teeth into and put on their resume. I forget which professional orchestra I heard -- not the NY Phil... maybe the London or the Berlin.

What struck me about the two performances was that I enjoyed the Julliard Symphony significantly more than the professional orchestra! Sure, the professional orchestra's version as technically perfect -- all of the complicated rhythms and counter-themes interlocked exactly. All the dynamics were there, the tempos were accurate and the precision of the performance was incredible. Amazing what a group of professional musicians do when they really concentrate!

The Julliard Symphony was not technically perfect -- a flub here or two. The themes interlocked beautifully, the tempos and dynamics did more than just give a professional orchestra a "run for it's money." They were professional. These were the best musicians in the country playing at the peak of their masters degree education. Here were performances by two groups who should have been on a par but, in my opinion, the Julliard orchestra blew the professional orchestra out of the water!

Why? The Julliard orchestra got excited over the music. You could feel in the crazy, fast, intricate sections that the orchestra was just one hair's breath away from flying completely out of control. The rhythms caught with milliseconds to spare almost like when you have two interlocking cog-wheels but they don't interlock well and there's that second when you say "oooh, it's not going to work" and then the wheels catch and turn to the next cog. The tempos pushed just on the leading edge of the conductor's beat with the conductor holding his students in with the sheer mental will of making them follow him instead of the other way around.

The professional orchestra, as I said, played the piece flawlessly. I cannot find any way to fault the performance but to say that during their performance, I sat back and enjoyed. During the Julliard performance I was on the edge of my seat, gripping the armrests chanting in my head "yes, yes, get that! Yes!! eek eek eek... yes! got it! go!" with my jaw hanging open at the sheer enormity of the performance I was witnessing. My head was reeling with the Julliard performance for days.

That's what classical music is REALLY about.

A sad story...

I know I just wrote an entire post pretty much criticizing my time on the pediatrics floor, but there is one case the will stick with me.

There was a patient who my service inherited from one of the other pediatrics services because the attending on my team was willing to take on this very difficult patient. Ms. M turned out to be a patient that I had seen around the floor on numerous occasions. I always wondered what was wrong with her because the poor girl was always crying and seeming to be in severe pain while walking around the floor. She looked to be about 12, always was hunched over, face contorted in pain, wailing or, on a good day, snuffling as she walked past with a feeding tube dangling from her nose. While working on the floor, I could hear wailing coming from her room on a regular basis.

When my team picked her up as a patient, I was curious to find out what was making this little girl so sick.... Turns out she wasn't a little girl. She was actually 17, looked 12 and acted 3. She had major depressive disorder, severe fear of abandonment and anorexia nervosa as a result. Ms. M was being force-fed through the feeding tube to keep her alive. She would periodically vomit up her feeds due to emotional distress. Her parents would string her along about visiting and then not visit for days on end adding to her fragile psychologic state. When her parents finally did show up the first week we had her, they asked if they could just take her home to let her die. Needless to say, they were sharply reprimanded for that statement by the senior medical staff. Unfortunatley, they had said it to Ms. M as well, which caused two days of the worst wailing and crying I have ever heard -- it was horrible to bear.

I always tell people that there are cases you come across that bring home the severity of a disease for you. Those are the cases that make you respect a disease entity. A prime example is Asthma. So many people have "asthma" (there is a theory, actually, that many who are diagnosed with asthma may not actually have it). There is so much mild asthma out there that it can be easy to brush it off as "not that bad." After seeing my first case of truly life-threatening Asthma, I will never underestimate the disease again.

For me, Ms. M is my bar -- my disease-defining entity for anorexia. To say I was shocked when I learned that she was 17 is an understatement. To watch her suffer with the psychiatric burden to the point that her parents were willing to let her die to relieve her suffering was jaw-dropping. Not only were those things amazing to me -- but to watch how a firm hand, a set of rules, absolute 100% structure could turn a patient around was one of the most interesting things I watched on Pediatrics.

Immediately after the "can't you let our daughter die" conversation, the attending on our team decided to structure absolutely every aspect of M's life -- including demanding and holding her parents to a daily visiting schedule with set arrival and departure times. She had a daily schedule posted in her room with shower time, school, nap, everything written in. She had rules about where she was allowed to do what -- she had to vomit in the bathroom, she was not allowed to have the vomit basin in her bed. There was much more the the elaborate plan, and somehow it worked. I returned from a weekend off to discover that M was eating of her own accord. Another week later, she was smiling as she walked the halls. Another week after that and she had befriended one of the much younger patients and we would seem them laughing as they walked. It was a different person from the one who had caught my eye my first days on the ward.

She has been transferred to a long-term psychiatric care facility specializing in adolescent eating disorders. I hope they can continue the work that was begun in the Children's Hospital and that someday Ms. M can go home to her family.

It's been a while

I know, I know, I'm a horrible blogger. I go for long stretched of time without writing anything!

Let's see, I was noticing that my last post was about Jason's wedding in Oklahoma. What have I done in the past month?? I've been on the Pediatric in-patient floor in the Children's Hospital of New York at Columbia. This is a rotation that has gotten fairly unanimously panned by my co-residents. I am pleased to say that it was more enjoyable than I was expecting!

As part of training for emergency medicine, we do a number of "off service" (ie- out of the ER) rotations. The goal is multifactorial. First, the foster relationships between the ER and other services. Second, to give us some compassion towards our colleagues when we wake them up at 3am to admit a patient. Finally, to hopefully teach us a bit about the specialty.

Here is the problem: (mostly, it's reason #3). Interns in places outside of the ER and pretty much overqualified underpaid secretaries without any responsibility to make clinical decisions. In fact, on the peds ward, the intern is the equivalent of a trained monkey. Clinical decision making is actively discouraged. I wrote notes, I put in orders, and I answered mundane questions. That being said, I had a good month. I got in a 6am, got my work 90% done by 7am, rounded until noon, had an hour off for lunch (!!!!!), rounded from 1:30-2:30, finished the last 10% of my work and then went home generally between 3-4pm. In-between I played lots of solitaire and had all my decisions made for me by my seniors.

Did I just say 3-4 pm?? yep. I did. I was like being a normal person!! And with Rob currently working from home, he was there! We got to eat dinner together, go out with friends, meet other people for drinks... sigh. We've never seen more of each other than we did this past month and that was worth all the frustration and solitaire-playing that occurred while on Peds. The number of game apps on my iPhone doubled over the past month... I kid you not.

What else did I learn from peds? I'm not going to have kids anytime soon. I can do the little babies, their cute and not that bothersome. I can do the teenagers -- despite the attitude at least you can talk to them (even if logic probably doesn't apply). Everything in-between I can do without. I am sure that when I do have kids someday I will be all about every phase of their lives... just hell no, not yet.

Sum up: it was a nice, relaxing month where my days were filled with an hour and a half's worth of work spread out over 10 hours and I got to enjoy having a wonderful relationship with a fabulous, handsome man. ;) siiigh... back to work (yessss!).

Ooooklahoma, where the wind comes sweeping down the plains...

Yep.

In the past 72 hours, I have visited 2 new states for me -- Texas... and Oklahoma. "Why?" you might ask. Rob's good friend from his childhood, Jason, got married this past weekend in Oklahoma City to a very cool gal, Cathy. Rob had the honor of being a groomsman.

When we first got the invitation, we just assumed the wedding was in Philadelphia. Or the midwest, where Jason used to be. Careful scrutinizing of the invite showed address, address, address... Oklahoma City. eep. Two hard-core northeastern city-ites had already RSVP'ed "yes" before realizing where the wedding was. So we sucked it up and went to Oklahoma.

We get off the plane and look around at the wide expanse of flat. Trees here and there, but mostly flat. Meh, it's the plains. (by the way, we had to look up WHERE Oklahoma was on the map in the airport). The airport was empty even though it's 3pm. Walking outside the terminal at the "taxi" sign we could almost hear the crickets. Not a car in sight. Fortunately a passing security guard showed us where the single taxi was hiding, behing a giant pillar in the outermost lane. He was a friendly guy, instantly chatting away with Rob (I don't handle "interested" cabbies very well -- too much paranoid new yorker in me).

By the end of the cab ride, Rob and I were giving each other the "oh dear god, what have we gotten ourselves into!?!?!" look. Fortnately, the cabbie was the only scary interaction in the trip. He did have one good line: He reminded Rob, "now, we here in Oklahoma are nice people. It's not Vegas. What happens here will get back to that pretty lady there."... I think I might have snarled at that point.

The city was dead quiet over the weekend. The downtown skyline is 3 buildings about 20-30 stories tall. However, the people (other than the cabbie) were great! The group at the wedding were highly educated, highly intelligent and very interesting people. Jason is in the Air Force, so a number of guests were in the armed forces or married to people in the armed forces -- mostly engineers. Cathy is a trained pilot and flight instructor who now sells private jets for mucho bucks whose friends were mostly aviation people. Both bride and groom are avid fencers and they actually met at the local fencing gym (this is how Rob knows Jason). It was a fun, friendly and eclectic group of people which made for a very nice wedding. Rob stood out a little as the one groomsman not in uniform, but Rob always takes all of that in stride.

Would I go back to Oklahoma as a tourist? No. Would I go back to visit Jason and Cathy? Definately! Am I still scared of Oklahoma (total state-wide population 3 million)? nope =). Just to note that there are over 3x the number of people in NYC alone than in the entire state of Oklahoma. Just for perspective.

'

Recap

Half way done with Intern Year!

how in the world did that happen!?! and why don't I feel like I've gotten much better and what I do? (in defense of that statement, I did ask one of the attendings one night when the feeling like I know what I'm doing thing starts happening... the answer was half way through NEXT year, so... )

Maybe it's just a "the more you know, the less you realize you know" phenomenon. I have had 2 successful intubations now (of 6 attempts), put in my first femoral line on my first try (yay for anatomy class), have seen cool stuff, have seen some sad stuff, have had patients drive me crazy and have had patients I really liked. I have figured out which Cornell attendings I like, which I love, and which one (singular) I could really do without.

by the way... I survived surgery. 'nuff said.

Now it's a new year and, for me, a new hospital. My entire second half of the year will be spent up at Columbia -- time to re-learn an entire hospital system, 100% new ER staff, new ordering systems and a different chart. Not to mention almost double the patient volume, at least half of whom don't speak any english. Columbia is the place where you don't bother to call the primary doctor because 90% of the patients don't have one.

wish me luck! (I'm gonna need it...)

Snowstorm!

... I would like to thank this snowstorm... for keeping the ER quiet... and only creating a few Saturday night drunks instead of a ton (although the one I'm taking care of is particularly vomit-y)

ER entrance, midnight.

And The Moral of the Story...

So, last night in the Cornell ER was a steady stream of interesting cases, notifications (EMS giving us a heads-up they are coming in with someone sick) and some unfortunate events.

There was the woman who tripped at a holiday party she was hosting. Turned out that she hadn't tripped -- she had had a massive stroke. Apparently there was some debate at the party as to whether she was just stunned from her fall or actually had something seriously wrong. One of the woman's friends basically said "I don't care what all of you think, I'm calling 911." Minutes are brain with strokes. The patient had tPA (the clotbuster drug) on board within 1 1/2 hours of onset of symptoms. For those of you who are non-medical, that's damn good. I later overheard the friend on the phone with other partygoers saying "See? I told you!! I saved her life tonight!" The patient's future is still very unknown (strokes are horrible and take months before a prognosis can be made), but that friend drew a line in the sand and as a result the patient has the best possible chance of making a meaningful recovery she could have.

Later in the evening a horrible case came in. A car pulled into the hospital circle and two young guys helped a third unconscious, pulseless guy out of the car, yelling for help. We brought him straight in only knowing that the patient had told his friends that he was having an "allergic reaction." Immediate CPR was started and the patient was asystolic (flatline). We worked on him for half an hour before calling it. It didn't make sense that this very young professional could present after an allergic reaction without any signs of cardiac activity. He never had a pulse, never had anything other than asystole... it was erie, strange and confusing. Young healthy people's hearts don't just stop. And he was young and healthy.

You work longer and harder on the younger patients for a number of reasons. There's the obvious -- the patient has so much left to life. There 's anothe reason, their hearts are more resillient. Let me explain: There was a heartbreaking arrest a few weeks ago in the hospital. A young, previously healthy person arrested on the main units. Every medical resident in the hospital that night assisted with that code. They coded her for two hours and eventually lost the patient. Why? Because they kept getting her back and loosing her again. This is how you expect young person arrests to be. Horrible, full of hope that gets dashed over and over again. I was in one on my surgery rotation. We kept getting a heartbeat back and we would all take a deep breath and feel the pulse... strong... strong... not as strong... moderate... weaker... gone... fuck! Start compressions!

Back to our guy from last night... he never did what I'm talking about. He was the same age as the other examples I gave, but his heart never gave an inkling. Maybe that was the most confusing part. It just didn't fit and it was hard. What were we missing? What was the silver bullet that would make this guy's heart wake up? We threw every drug we had at him -- nada.

Over the hours following his arrest, more of the story of the events of the night came to light. He had severe food allergies. He was at a holiday party for work and started to have an allergic reaction. People wanted to call 911, but the patient wouldn't let them. He and a friend went trekking across the campus of the facility to go to his locker in search of an Epi pen. None to be had. Then back to his office -- maybe it was there. Nope. They decided to drive him to the hospital but the car was in the 3rd sub-basement. The patient got in the back, his two friends in the front. At this point, the patient stopped responding to his friends. They drove... but they didn't know where the hospital was. It took them 10-15 minutes to find us. The rest, some might say, is history.

No one is to blame for any of the events in any of the examples here. The young man's friends lifted him and carried him bodily into the ER for help. They yelled encouragement to him from the other side of the curtain. The older woman at the party had significant slurred speech seeming like confusion.

The lesson is that one of the hardest thing to do is to stand up to your friends. To go against the group decision or against your friend's own decision. To be the "bad guy" who caused embarrasment by calling 911 for "nothing." It might not be nothing. Forget all that "do what is right" bullshit -- I think it is nearly impossible to live a completely morally just life. I would say, if you're scared, do what will make you un-scared -- whatever that may be, I find that it usually involves getting backup.

Happy Thanksgiving!

Happy Thanksgiving, everyone!

I find myself in Philadelphia with Rob's family for the second year -- something which I enjoy very much. It's always fun to be with someone in their "native habitat"... in Rob's case, this consists of his mother (who has a special place in my heart for putting me up last year for an entire month), the younger bro and lots of family friends. Thanksgiving this year was a big event consisting of 13 people around one giant table in one tiny dining room. The food didn't fit (never does) so it lived on a separate buffet table. There was a wide smattering of ages from high school, college, us 20-somethings, some 30-somethings and, of course, the parentals who were actually the significant minority!

All in all, yummy, warm, excellent wine selections (thank you, Rob) and then a nice long lie-down on the living room floor in an attempt to digest. Good time =).

The gang...
Nan, Lucas, Ryan, Angela, Marcelle, Alex, Nora, Danielle, and Jeff
in line for the buffet =).

Vacation, Part Deux

Where did I last leave off... oh yeah, in DC, at G's. DC was great -- Genevieve and I went to the National Opera Trunk sale and got great halloween costumes (see bottom of page).

Chicago was tons of fun -- Aileen was slaving away in MICU (ugh) but still managed to take me to FlatTop -- one of my FAVORITE restaurants of all time! FlatTop seriously needs to come to NYC... I say this when they only just arrived in downtown Chicago. Aileen took me to the new location in the Loop that has only been open for a few months.
Ashley took care of me for the rest of my chicago stay, including super yummy oysters at Shaw's Crab House -- live music, fab seafood. Overall, the dinner (with two glasses of wine each, and dessert) was incredibly reasonable!! Not something you would expect from a restaurant just off the Loop, valet out front and the after-work-suits piling in. We opted for the significantly more casual Raw Bar half of the restaurant due to the jeans we were wearing and LOVED it!

From Chicago, I jetted off to Seattle to visit Dave and Katie. Katie and I spent the day bumming around Seattle with a trip to one of my favorite stores ever -- Fireworks, and then the Seattle Mystery Book Shop which is wall-to-wall, floor-to-ceiling Mystery Novels. Katie was in heaven.

The highlight of the stay was definatley dinner at the Purple Cafe and Wine Bar with Dave, Katie and Nolan!! It was great to see Nolan -- who I hadn't seen in literally 5 years! The four of us caught up, tasted through a bunch of wines and had a fabulous dinner.

I highly recommend the restaurant -- it is a new favorite of mine in Seattle! The wines are great, the food is delicious, but the also have a sense of humor. The wine list opens with "The Book says "the apple tempted eve."... our book says "it must have been the grape."" The entire list is covered with little jokes. I still know next to nothing about wine, but we ordered a few fleets of which each fleet definately had one "looser" wine and one major "winner" wine.

Of the "Bullfighter" flight of 100% spanish wines (we ordered it as a tribute to the absent Rob), Atalya Amansa 2007 was the winner. From the "Pino Noir" fleet, the Erste & Neue Kellerei "Mezzan" 2007 from the sudtirol-alto region of Italy was the clear winner. Rob wrinkled his nose when he heard that, but it was the best of the bunch!

Returning to NYC and work kindof sucked. It was so great to see everyone, but time flies. I'll leave you with a Halloween picture displaying the awesome Kimono costome I picked up with Genevieve in DC!

Rob, Me, Elena and Alex on Halloween.

Enjoying NYC once again...

Took a while, but I finally got back around to enjoying NYC -- or just enjoying everything in general. I just finished a month on the Acute Care Surgery service at Columbia Presbyterian Hospital. I learnt a lot, I worked hard, did 30-hour call (horrible) and actually had a good time. The Surgery residents at Columbia are a fantastic group of people and I had the tremendous help of someone who has helped generations of NYP EM residents survive surgery -- Voula, the acute care surgery service PA. If most PAs are worth their weight in Gold, Voula is worth her weight in Platinum. phew!

First, there were the 3rd row seats in the endzone at the Eagles game in Philly...
I was going to go SCUBA diving during this time off, but that all fell through, mostly due to the fault of annoying bosses and failure of appropriate planning. Oh well. That's why I live in NYC and can salvage! Then there was taking Deka to the dog park (she was spade and forbidden to run for a month). She was so excited, she ran laps for the first 15 minutes. Deka is now 9 months old!!!

Thursday found me at Carnegie hall with Elena to hear Hayden's "The Seasons" -- a piece I was completely unfamiliar with. Turns out that Hayden drew significant inspiration from Handel's Messiah for this work and it was really beautiful! Full orchestra, full choir, soprano, tenor and bass soloists. Each "season" was unique. Spring was calm and pretty, Summer was a little weird because it had a sad feeling to it, however Fall was fantastic with the "hunt" and the french horns going bells up and balls out crazy and Winter was full of BIG choral stuff with a necessarily rousing finish.

All of this was followed by a weekend in DC w/ my college roommate, Genevieve and her husband, Bren which included a stop by the National Opera Company's Trunk Sale where they were selling old costumes -- both G and I walked away with kickass halloween costumes from Madame Butterfly (Bren stayed home).

Now I'm in Chi-town visiting Aileen and Ashley. Irony of ironies, it's actually warmer here than in NYC (as in, 53 instead of 48, but I'll take it). From here I go to Seattle to see Dave and Katie for the first time in almost a year and a half!

..More pictures later. I kindof forgot my camera charger, so I'm taking pics VERY sparingly. oops.

NEJM does it again!

So, I'm browsing, killing time (on vacation, I might add) and decide to see what's doing on the NEJM website. I get there and the top story on the website is this: Interactive Medical Case- A Bloody Mystery.

Wait... interactive?? So I click the link and guess what? This is FABULOUS! There is a reason why the NEJM is considered the preeminent medical journal and innovations like this are it. This is a case, presented in pieces (the usual horrible puns apply) with frequent breaks where you "order" lab tests and "create" a differential diagnosis then reassess and "order" more tests/treatments. There are charts, tables, MOVIES, images. Even better, this isn't the "one correct answer" format. It's the "which 5 of these 15 potential diagnoses could this patient have?" There also isn't any sort of giant ERROR buzzer, either. You choose your answers, the green checks and red "x"-es appear and you read an explanation of the answer.

Did I mention the excellent explanations? Sometimes a little too helpful before you click on your answers, but that's what learning is about, right?

NEJM is famous for its long-established "Case Records of the Massacchuttes General Hospital" in which docs get to read a round-table discussion of a complicated case with a number of experts weighing in. Very valuable -- med students everywhere are told to read it -- but its dry and complicated as hell to follow. They literally transcribe the round-table discussion verbatim. I feel that this new interactive case format accomplishes the same goal but I actually learn becuase I'm participating and actually care (I admit it... I don't like to get questions wrong).

Overall, two thumbs up.

While I'm at it, I'm going to put in a one-line plug for the NEJM "Image Challenge" on the website. This shows pictures of pathology -- anything from photographs, radiology, microscopy, gel electrophoresis...etc. You pick the answer from the multiple choice on the side and get told right/wrong. Quick, visual recognition, great for keeping your brain plugged in on overnight where you have to stay awake but don't have the energy for more than a mouse-click.

Could Hawai'i be generalized?

There is an article in this weekend’s NY Times that I found very interesting. It’s about the healthcare system in Hawaii – and how GOOD it is! The authors cite that Hawaiians live longer than any other state in the union and they they are generally healthier. The doubters among us say “no shit, Sherlock. It’s BEAUTIFUL all the time!!” However, there were some more intriguing tidbits in the article that made me wonder. Hawaii has the highest rate of breast cancer in the US, however, they have the fewest DEATHS from the disease of any state. Hawaii has the highest percentage of insured in the US and the lowest Medicare costs (possibly again contributable to that whole tropical paradise thing).

But really, the least number of uninsured? Massachuttess has the next lowest number of uninsured at 20%. Hawaii’s uninsured # is 10%. What’s going on? There is a law in Hawaii that every employee who works a minimum of 20 hours per week must have health insurance. Sure, there are people who try to circumvent the systems, employers making sure their employees only work 17 hours per week so that they don’t have to pay insurance, but generally the plans are cheap, no deductible, widely accepted and easily suffice for your average fairly healthy tropical paradise inhabitant.

I was puttering along this article until I hit the section where they start talking about the ERs in Hawaii. The author interviewed an ER doc who spends part of his year in LA and part in Hawaii. He described the Hawaii ER experience as “greased lightning.” Nationally, there are 400 ER visists/1,000 people annually. In Hawaii, that number is 200/1,000 people – half the national average. Again, you could make the tropical paradise argument, but Hawaii is not without its dangers. Anywhere there are highways, there are high-speed car wrecks. Just because the live in paradise doesn’t mean that Hawaiians don’t suffer from heart disease, asthma (highest rate in the US), COPD. Not to mention the kind of trouble the “touristas” can get themselves into with the vast number of adventurous activities available in Hawaii – there’s surfing, jellyfish, climbing, diving, parasailing, base jumping, heat stroke… all recipes for tourists ending up in the ER.

So why is this mystery ER doc saying that Hawaii’s ERs are “greased lightning”? The theory proposed by the article is that there is much better access to family care practitioners and general primary care docs, so patients go to their doctors for all the minor stuff rather than to the ER. i.e.—appropriate use of the primary care physician and the ER. This is something that I am continuously advocating as the root of our healthcare crisis—lack of access to primary care. I also always say that this is not going to be fixed without a massive expansion of our clinic system. The system as it is right now is at its breaking point on all fronts. This is the point at which Rob jumped into to play devil’s advocate.

What is the ratio of primary care physicians to population in Honolulu vs. NYC or Philadelphia? Barring that, what is the population difference? What kinds of numbers is each hospital on Hawaii serving in beds per population vs a NYC hospital? How many insured use the ER vs. primary care for minor complaints? How sick ARE these people in Hawaii (tropical paradise argument again)?

I’ll have to do more research and get back to those valid questions. For now, it appears that the spin on the NYTimes article agrees with my personal opinions – we need more primary care!

Hawaii’s system is not without problems. A number of the hospitals, especially on the outer islands, are failing. The rate of uninsured is increasing due to the current economy and the system is not built to handle the uninsured right now – it is a system built to handle almost 100% insured. It is interesting to wonder if the resources and the finances will be able to withstand what is to come. Also this whole “greased lightning” thing… I can’t see it. Maybe an entirely decompressed healthcare system works. I just don’t know.

Puppy Update!!

My parents are still gladly suffering through "ridgeback puppyhood" with Deka, who is now 8 months old! Rob and I went over for some sukiyaki the other night (and some furrball time).

Sukiyaki = the best food EVER. Japanese mish-mosh of yumminess.


Back to the nonexistent point... I was really impreesed with how Dek is doing! She is obeying commands and actually didn't eat a single scrap off of hte knee-height coffee table! The whole point is to just share some pics to the pets! =).

Sashi looking regal as ever :) (and begging for food)

The not-so-small-anymore baby looking somwhat sad at having to be good.

Felix finally figured out a way to hide and still be pet --
the pup can't see him, but we can!

Oscar is more brave...venturing all the way out to the couch.

The Tale of A3

I've been working night for almost a week now. I like working nights -- I prefer the patient population and the structure (starts out busy, tapers off) and by about 2am, whoever is coming in is genuinely sick. That being said, there can be nights like last night (I slept!) or there can be nights like what is now being called "A3 night" among the residents.

I walked into shift. The ER was packed, the rack had 3 or 4 charts in it, the signout was clean (fortunately!) and I picked up the first chart -- 50 year old guy with syncope. groan.
(translation of above for my non-medical friends: there were 3 or 4 patients to be seen, signout is patient handoff from one doc to another at the end of shift so that care continues and being "clean" means that there isn't much to do on the patients who are being transferred.)

Syncope (fainting) is the presenting complaint for 1-3% of annual ER visits nationwide. There are over 112 million ER visits per year according to the CDC, making syncope account for up to 3.3 million ER visist per year. As a comparison, "chest pain" accounts for approximately 6 million visits per year. So yeah, syncope is common. Of pateints complaining of syncope, only 34% get admitted to the hospital and, of those only about half actually get diagnosed with a cause for their syncope -- this doesn't take into account the patients who complain of syncope and then upon further questioning turn out to have had "near-syncope", aka- lightheadedness. I couldn't find a number for how many patients fall into that category, but I promise you it is a LOT.

Back to the "Tale of A3"... I'm looking at my guy, who is sitting up, awake, alert, telling me he feels kindof silly for being in the ER. I haven't laid hands on him yet-- we're still in the talking phase -- his monitor looks good, EKG normal, normal heart rate, normal blood pressure, normal oxygen content, but first thing I notice is, "wow, this guy's story sounds like he really did loose consciousness!" He doesn't have any medical problems, no medications, no allergies, no ciagaretts, no alcohol, no drugs, nada. I ask if he felt anything funny before passing out and he looks at me and says "You know doc, I'm kindof feeling it right now. A headrush thing..." aaaaand he's unconsicous. I look at the monitor and he is asystolic!!!! Heart NOT beating. Well fuck.

I call for help, sternal rub him to wake him up, I'm about to lay him out and start chest compressions when he wakes back up! He was out for about 5 seconds -- by the time the rest of the ER staff arrives they're looking at me like I'm crazy because his heart is beating and the patient is like, "I can't believe I passed out again!!" This episode made number 3 for the day.

He does it a fourth time about 20 minutes later, this time while the nurse is with me. Everyone sees that one. We need cardiology and we need them 5 minutes ago. I go directly to the top and page the SENIOR fellow (this is kindof ballsy for an intern) "ED STAT"... I didn't even leave a phone number. (later he told me he thought that the page was hillarious) But he appeared in about 2 minutes, so it had the desired effect.

Recap: I have a patient who is going periodically flatline on me, crash cart is OPEN at beside, code meds are already drawn up into syringes, the senior cards fellow has no clue what is causing this becuase the guy's EKG looks like it could be in a textbook under "normal," and the patient is looking at all of us like we're crazy 'cause he feels fine.

He can't be moved from the ER becuase what if he goes asystolic and this time doesn't spontaneously recover. It's too dangerous for him to be being wheeled down a hospital hallway when that happens. But he NEEDS to be in the cardiology intensive care unit.

The decision is made that we need to put in a pacemaker in the emergency room to take over triggering heartbeats when he heart pauses. It's simple -- we thread electrical wires through a vein in the patient's neck into their heart. However, before we can do that... the patient's heartrate starts to slow to the 20's. We're all thinking, "here he goes again!" Nope. This time, he has a seizure! (actually, "seizure-like activity"... medical technicality) and afterwards he is vomiting, confused and has zero short term memory. We went from conversing with and intelligent, cognizant guy to: "wha? who're you?" "I've been passing out? NO WAY! SERIOUSLY? duuuuude." "Why is my wife here?" "Wha? who're you?" ... repeat. He couldn't follow commands any more because he couldn't remember them and he was vomiting on top of that. The decision was made to intubate the patient to protect him from inhaling vomit in his confusion.

After that, things went much more smoothly. He had another episode of asystole while I was placing the pacemaker (I got to put in a transvenous pacemaker!!!! SO COOL!), but otherwise, things were ok. He went up to the Cardiac Internsive Care Unit where he got a multi-million dollar workup, a permanent pacemaker was surgically placed and he was discharged after 4 days -- the cardiologists still had no clue why his heart was stopping.

That was the first 4 hours of my shift. Cleanup takes an hour (the room looks like a hurricaine hit it). Next up in A3 was a ruptured ectopic pregnancy who got rushed to the Operating Room in about 20 minutes flat. We were able to diagnose her rapidly with a life-threatening condition and get her to help. Later, the Ob/Gyn came down and told us that she had over 3 liters of blood in her belly and they were able to successfully stop the hemorrhage. Yowzer.

Clean the room again (antoher hour becuase it looks like another hurricaine hit it after the ecotpic -- running around to get IVs, blood, fluids, ultraosound, yada yada.) and a little old lady comes in. Another syncope. Moderate language barrier and no one around who speaks Mandarin, so the story is fuzzy, but it sounds like she's having seizures. However, she's sitting in bed looking all cute and normal. Ok, chill out, we'll get Neurology. Neuro's evaluation gets interrupted becuase a stroke rolls in, whatever, she's fine.

All the docs are chilling back in the doctor's room, we're tired, it's been crazy, things are finally settled, the stroke is in the MRI and it's 6am. The overhead comes, "doctor needed in A3." again!?!?! Yep, little old chinese lady is having a seizure. Well, at least that's confirmed. She's gonna be admitted to Neurology. However, her seizure isn't breaking despite medications. Takes about 20 minutes, but we finally get the seizure to break and once again, the room looks like a tornado hit it. The nurse is begging us not to put any more patients in her room and just let her finish the last hour of her shift in peace!

Fortunately, that is exactly what happened. =)

I leave in the morning, sun is up, it's a hot August day and I look around -- it's weird to be outside. Every once in a while we get a gift. A reminder of why we spend our days and nights inside with beeping machines, no windows, drunks, crazies, the smattering of rediculous complains, disgruntled people and admitting residents who resent that you are making more work for them. The story above is why. This is what I do. And this is why I do it. Damn straight.