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.