LEAP

On Tuesday, my day off, I visited the LEAP (Learners' Expanded (?) Academic Potential = Gifted/Talented) class in my hometown of Kilgore. I went to LEAP as a kid once a week all through elementary school. This time, I returned as a doctor to talk to the class.

I was expecting the room to be much smaller than I remembered it. Maybe it was because I'd prepared mentally for that, I was rather underwhelmed with the discrepancy. Really, things seemed about the same, only now there are computers in the two classrooms in LEAP's portable building.

The fourth-graders I spoke to were charming--bright, interested, and full of questions! Though half the time, when the children raised their hands they had more of a story than a question. I think adults do this too, but they're just more sophisticated about it.

The kiddoes are starting a unit on economics, so I did a little research to share. The U.S. spends 1.7 trillion dollars on health care annually (in 2003), and 180 billion of this is on prescription medications. The entire GDP of the U.S. is 11 trillion dollars. I wanted to help them get a feel for how big these numbers were, so I started by drawing a "1" on the chalkboard, followed by zero after zero. The kid who stood up when I'd drawn enough zeros to represent one trillion got to help me demonstrate the physical exam.

We also talked about what kind of doctors there are, the education involved in becoming a doctor, and the common health problems confronting the U.S. (smoking, diet habits, little exercise) --> (obesity, diabetes, high blood pressure, cancer) --> (a multitude of medical problems including heart disease, strokes, kidney disease, amputations, blindness)

All in all, it was quite rewarding and fun. Here's a picture of Peyton, the boy who knows how big a trillion is. He was a good sport as I showed them how to listen to heart and lung sounds and elicit reflexes.

My last night at the hospital...for a while

For two monts, I have slept (or at least spent the night) at this hospital every fourth night. Tonight is the sixteenth such night of doing so before a month's respite! I rotate "off service" at 0700 tomorrow, which means I don't have to round post-call...it'll be beautiful!

This evening, I spent a couple hours doing evening rounds and writing "off service" notes for the intern coming on the team after me. These notes are essentially a summary of the patient's main (recent) issues and what we're doing for them. In other words, they're an expanded version of a daily progress note's assesment and plan.

It was kinda gratifying to see my patients one last time. On four separate occasions this evening, the patient or his family explicitly thanked me for my care! One of these patients is my pancreatitis patient from New Orleans who's been here nearly two months. His mother gave me a big hug when she heard I was going of service. Sadly, this patient and his wife have lost their home in the hurricane.

Ironically, one of my new patients today is also from New Orleans. He was evacuated from a hospital which had lost power there. My attending physician chose this patient as one to watch (and evaluate) me do a history and physical exam. I was a little self conscious doing so for at least a few reasons: 1. I was being evaluated. 2. Immediately before we walked in the room, my attending said, "Is that a little spinach caught in your teeth?" 3. The patient is a retired internist.

For another 83 year old patient and his daughter, I spent 15 minutes answering their questions about West Nile Virus. When I quickly realized that I hadn't read enough about this diagnosis we made today, I printed out a patient hand-out and spent some time going over it with them.

So the evening "tuck-in" rounds continued (see DoctorJ's medical slang glossary)... I love telling patients, "I'll be here all night. If anything comes up, please have the nurse give me a call." The beauty of it is that this is exactly what would happen anyway, yet it comes across as a very thoughtful and caring thing to say!

Here's a picture off the internet of a patient needing to be tucked in. Notice she's still sitting up. A milligram of Ativan will help with that. Also, her covers should be pulled up and her side rails raised. She must have some obstructive sleep apnea because I see some CPAP equipment in the background. And does she have IV access? I'd definitely get a line in before bedtime.

Well, it's 11:00, and the pager has been quiet for a while. Maybe I'll get some sleep before 7:00 AM!

This bothers me

As I've mentioned before, one of my favorite parts of the Sunday paper is thumbing through the Parade magazine and reading the column "Ask Marilyn." I was mildly irrated to be stumped by a geometrical puzzle submitted by a reader. Of course Marilyn found an elegant--and correct--solution.

Toward the back of the magazine, I noticed a full page add for a "Faberge-inspired Tribute to a Departed Loved One." This is, in essence, a decorated egg on a pedestal which opens to reveal a winding staircase leading up to a cross. The egg "Plays the touching melody of Amazing Grace" and features "More than 175 sparkling faux jewels." All this is yours for "two convenient monthly installments of just $19.99."

What disturbed me was the inscription on the base of the pedestal.

If tears could build a stairway,
And memories a lane,
I'd walk right up to Heaven
And bring you home again.

Calatrava

This new skyscraper is evidently the tallest building on the Scandinavian penninsula. Designed by the famous architect Calatrava, it boasts a view of Denmark from its upper floors. I like the twisting effect. (More info here.)

More things I'll miss about this city...

1. Vespers, the quiet, meditative mid-week communion service at my church. I've always appreciated how compact this service is--short, yet full of great liturgy. It's an often much-needed pause in the midst of a busy week. And I love it when autumn turns into winter and the evenings get darker and the air becomes crisp...still, week after week, there's Vespers.
2. Watching the meteor shower my first year of med school, with friends, in the back of a truck. Sure, we should have been studying for our anatomy finals...
3. The opportunities to spend time with the homeless at the downtown shelter and the one where my church visits. It was in these places that I came to realize how approachable these people are, and that despite the differences in our education or what we wore, we really had a lot in common.
4. Ethnic shopping. This ranged from the Vietnamese grocery "V-T Mart" down on Maple, to the local Carnival with more choice of tortillas than bread, to Chinatown with its dim sum and milk pearl tea.
5. The toll road. First off, it feels luxurious to take it as a fast route between points A & B. And secondly, it provides a change of perspective on buildlings and places I frequent from the streets.
6. The fact that it's close enough to my parents' house in the country to caravan out to G-town with friends. We've done this several times, and people seem to enjoy everything from the dog Shacor to the ducks and the pond, to visiting the festival on the brick-lined streets by the railroad tracks in historic downtown.
7. Smoking a cigar with friends on the balcony. This works well with a short tumbler of Scotch.
8. The county hospital. Dirty, inefficient, difficult nurses, lots of babies. On the medicine wards, we were bound to have interesting cases. And we could count on nearly 3/4 of our patients' medical histories including diabetes and hypertension.
9. The ice storm during our second year. An extra credit question was given to the medical students who braved the roads. Clay stayed over at our place since it was closer to school. In the morning I made my famous "Flour-n-water" biscuits.
10. Our Family Practice rotation. Flora, Clint, Amber. Working out, cooking, Smallville, turning the A/C down as low as it would go, running around the college campus, studying at the law school. Those were the days!

Lake Atitlan

A friend of mine recently returned from Guatemala. One of her favorite parts of the trip was seeing the beautiful and famous Lake Atitlan. Coincidentally, this lake is where my dad spent a a good part of his youth. Their home was on the shore, and he has memories playing with his brother beside the waters, which would get choppy every afternoon when the wind picked up.

I've always taken delight in teasing Dad about his reminiscing about Lake Atitlan--the most beautiful place in the world, he would say. A quick Google search revealed, however, that the place is amazing... Hope you enjoy these pictures.

These appear to be Guatemalan children. For some reason they came up when I searched for Lake Atitlan. I don't know if guys are allowed to use the word "precious," but if so, I'm certain that it would apply to them.

Dancing nun

I'd wondered what went on at World Youth Day. (Please see the following CNN.com article: Nun rapped for wild dancing.) I'd sure hate to have Mother Superior waiting for me every time I came home!


* disclaimer: The above picture represents a different dancing nun and is provided only for illustrative purposes.

Jonathan, victim of circumstance...

So there I was at the hospital today, minding my own business, trying to get my work done. I realized that with one patient, we were getting nowhere with our workup of his baffling neurological symptoms, and it was time to consult neurology. (I'd already discussed this possible plan of action with the attending yesterday.)

I called the answering service of the neurologist on call, and within fifteen minutes the neurologist paged me. I was in the ICU, so I promptly picked up a phone and dialed. I'm in a habit of deleting pages as soon as possible so that my pager nearly always displays the wonderful message, "No new messages," and today was no exception. As the phone rang, I deleted the call-back number, thinking it would be a quick conversation.

"Hello? ...Hello?" the neurologist said. I answered back, but he continued, "Hello? Is anyone there?" Obviously he couldn't hear me and soon hung up. Having no way to redial him, I went through the answering service again, which took a few minutes. "Sorry, I had deleted your number before I realized you could hear me. Could you please page me again?" Within five minutes, I'd received a second page with his number.

When I dialed the number, however, I got an error message, "This is not a working number." He'd typed in his number wrong. So I called the answering service back, taking a couple minutes to navigate through the computerized options, and left a message saying the number left on my pager was not a working. A few minutes later, I was paged yet again, but this time with a partial phone number.

As I sat there, trying to figure out what to do next, I received a fourth page, this time with a full ten-digit number. I dialed it...at last, it rang! And even though I used a different phone in the ICU, still the neurogist couldn't hear me on his cell phone. "Hello? Hello?" he said. Exasperated, his angry voice exclaimed, "Don't you know how to use a phone?!?"

I decided to go to a different nurse station and try to call back yet again. Finally, he answered AND he could hear me! But by this time, the conversation was off to a bad start, and I felt like he took every opportunity to point out how inadequate and insufficient our work-up had been of this patient. "Get an MRI-head, and if it's negative, then do a lumbar puncture, and THEN if you can't figure things out, give me a call and I'll come see the patient."

*sigh* Days like this make me tire of internal medicine. At least in a mere ten months I'll be doing anesthesiology!

Vioxx

$253 million??? I thought this seemed a bit absurd. (see link)

I'm in no way defending Merck or excusing them for the possibility of obfuscating risks. But it seems to me that although the studies show a nearly doubled risk of cardiovascular events (heart attacks & strokes) in patients taking the drug for 18 months or longer, it would be difficult to prove that any particular patient suffering an MI or a stroke would be in the statistical group over and above the basline group at risk for these events in the placebo arm of the study.

In other words if 1/1000 of the placebo group had a heart attack and 2/1000 in the Vioxx group had a heart attack, would Merck be responsible for both patients suffering heart attacks in the Vioxx arm? Or would it be resposible for 2-1=1? And if so, which one?

I acknowledge too that having seen billboards advertising for class-action Vioxx lawsuits and knowing the sometimes greedy, litiginous, and dishonest nature of the American public may sway me unduly toward the drug manufacturer's side. Then again, 90% of the settlement is punitive--for dishonesty in advertising, I presume--and it seems just a little out of the realm of 12 small-town jurors to set such a precedent for the inevitable and numerous cases to come.

It sure is nice to have a personal forum! Comments are welcome.

A day at the lanes

So we had a "Residents' Retreat" today...we met for lunch in the conference room, and then it was announced we were going bowling. The 15 or so residents were accompanied by the chairman, the associate program directer, as well as the assistant program director. And the "maternal" administrative assistant.

It had been quite some time since I last bowled. Can't say I'm a huge fan of the sport, but the three hours there sure beat admitting patients at the hospital, as today I'm on call! I found an inverse relationship between the speed with which I bowled and the number of pins I'd knock down.

At one point, the chairman joined our threesome and played a couple games with us. Clay noted that the attendings were much less intimidating in the bowling alley than in the hospital! At one point the chairman commented to me, "Go right for that 1-3 pocket." When I asked him what he meant, he explained how the pins were numbered, and right-handed people should aim for just between the closest pin and the one to the right of it. When I asked why that was better than straight on, his answer made me wonder if he thought I was really dumb: "Because that's how you'll knock the most pins down."

Besides the bowling, people-watching was kinda fun too. There was the guy in the lane next to me who would remove his glasses nearly every time he got a strike or a spare. There was the girl on my team who was "like a tornado" according to Clay--she could strike anywhere. In other words, her stroke ranged from rolling the ball to tossing it several feet before it loudly hit the lane! And then bowling at the lane to the other side was the professor who would quickly approach the lane and then stop (losing all his momentum) before releasing the ball.

10:00 PM...time to get a little rest before I get called next!

"Total, total chaos"

That's how the Associated Press article's headline began. The event was a used laptop sale in Richmond, Virginia on August 16th. The subtitle read, "17 injured while trying to buy $50 computers in Virginia."

Even though I felt like I should be disgusted, something in me was somehow delighted to read such a story! I couldn't believe I was reading it in a reputable news source. I've excerpted some quotations below:

"A rush to buy $50 used laptops turned into a violent stampede Tuesday, with people getting thrown to the pavement, breaten with a folding chair and nearly drivcen over. One woman went so far as to wet herself rather than surrender her place in line.

"'This is total, total chaos,' said Latoya Jones, 19, who lost a flip-flop in the ordeal and later limped around on the sizzling blacktop with one foot bare.

"...When the gates opened, a mob scene ensued. People threw themselves forward, screaming and pushing...

"Jesse Sandler said he was one of the people pushing forward, using a folding chair he had with him to beat back people who tried to cut in front of him. 'I took my chair here, and I threw it over my shoulder and I went, "Bam."' the 20-year-old said, his eyes on his new iBook, as he tapped on the keyboard at a testing station. 'They were getting in front of me, and I was there a lot earlier than them, so I thought that it was just,' he said."

Latoya's flip-flop

Catching up

I'd been so regular lately! I'd be lying if I said this last call didn't have anything to do with my lack of blogging lately. The day wasn't terribly busy, but we had a late admission, and then worked from about midnight to 1:30 AM trying to put in a central line on a demented elderly lady. I tried for about 10 minutes to find the femoral vein, my resident tried for another ten minutes, and then the attending spent 40 minutes, all without success! Obviously it's not comfortable to have a needle jabbed into one's groin, but I feel better knowing that it was necessary to get fluids and medicines into this lady, and she probably won't remember much as she was clearly altered.

I do have to say that after the hour of frustration, we eventually decided to change locations. I was up first (again) to attempt to access the left subclavian vein...and I got it first stick! Wish we'd started there.

After rounding on a few patients, taking care of issues and checking labs, I went to sleep at 3:30, hoping to sleep till 6:30. A call at 5:30, however, meant otherwise. A nurse told me that my patient was tachycardic (fast heart rate) and "doesn't look good." I went to assess her and when I noted her supraclavicular retractions and cold extremities, as well as the fact that she was pretty much unresponsive, decided transferring her to the unit would be a safe bet. I began those arrangement and paged my resdient.

For the next three hours we worked to stabilize her. Her ABG indicated her breathing would soon tire, so it was decided to intubate the patient. Since I'm going into anesthesia, I was eager for the first shot. The airway was obscured by thick, mucous-like secretions, and after I suctioned those, I could barely see the trachea, even using the best technique I could remember after spending two months on anesthesia. I couldn't get the tube in. Once again, my resident tried, then the attending. Even though we could still mask-ventilate the patient, it was becoming more urgent to intubate her. I called the O.R. and requested that any free anesthesiologist come to our assistance, as it was still early and the pulmonologists who usually work in the ICU weren't there yet.

A feeling of relief swept through the crowded ICU room when the anesthesiologist, accompanied by his OR nurse, showed up. Of course he nailed the intubation first try, but did note that the oversized crash-cart blades weren't ideal, and that the patient did have a very anterior larynx.

I didn't make it home till 3:30 PM. After reading the paper and having a bowl of cereal, I settled into a delicious slumber which lasted from 5:30 until 5:30 the next morning! I remember awakening around 3:00 or so and in my confused fog worrying I might develop a sacral decub from being in bed so long...

Move over, Emily...

My sister would say that Ms Dickenson has already garnered more than enough exposure in my blog. So we turn now, instead of to a Protestant poet from New England, to a Southern Catholic writer. That's right, Flannery O'Conner. I've read enough of her short stories to appreciate her brilliance, but still find her enigmatic. I once read that it's impossibile to dissect her short stories to find the meaning; the meaning is in the whole. And as a Christian, she invariably includes a moment of grace in her plots. Granted, this moment of grace may be lost on the reader who's swept away in her sea of absurdity, but it's there.

In his book Everyday Apocalypse: The Sacred Revealed in Radiohead, The Simpsons, and Other Pop Culture Icons, David Dark writes, "Whenever someone speaks favorably of Flannery O'Conner, I want to hold their face in my hands and look deep into their eyes to see if I can't detect some maniacally enlightened clarity of vision. If you're not against her, you're for her. And if you're really for her, I can't help but think that you've been, to adapt a phrase Faulkner applied to Joyce, electrocuted by divine fire..."

So I now turn back to Flannery O'Conner as a break from the final chapters of A Brief History of Time. Signing off for tonight...

A shocking lack of cultural sensitivity...

Another call day gone by! For these two first months on wards, that's 11 calls down, five to go. (Not that I'm counting!) Today I had the rather sad task of calling back a concerned 20 year old daughter of a patient and telling her, "I'm sorry, but your mother hasn't given us permission to discuss her medical diagnosis or treatment with you." Evidently there's a lot to the story I don't know, but mother and daughter are somewhat estranged.

Then there's my patient with stage IV gastric cancer. All of our treatment is essentially palliative. He's 41 and has children and a loving wife and brother who are at the hospital every day. I really enjoy going to see him because he's a nice guy and never complains, but I've realized lately that I'm a little in denial about the fact that he's dying. Of course, he's not dying in my world. We've got him nearly stabilized, and he'll be ready to leave the hospital soon, hence exiting my world in pretty good shape. But without realizing it, I've been acting of late that my world is his world. Even though he's stabilized, he's still facing death--likely within months--and I wonder what else I can do to be his physician...

On a lighter note, the title of this entry comes from a story related to me by my hispanic resident. She'd seen one of my patients today after I'd finishd rounding, and called me to ask if I'd noticed my patient's red face. No, I hadn't, it looked fine when I saw her. "Half of her face was all red!" my resident explained. "She said she'd been lying on it."

"Oh, I guess that explains it," I replied. My resident seemed surprised. "Oh...so that really happens with white people?" I assured her that yes, if I were to lie on my face, it would turn red too. There was nothing to worry about. And then of course I teased her, and will probably do so again at least once or twice for her concern about my patient's red face!

New York, here I come! (Part 1)

While I still need to continue my list of "Things I'll miss about this city..." I thought it would be fun to start anticipating the city I'll move to. Several of you know that the residency program I ranked first wasn't necessarily my favorite in and of itself; factoring in the City of New York and proximity to family in Philadelphia, however, gave this program the edge.

The following is a view looking south(west) from the Upper East Side. In the foreground are the Chrysler and Empire State Buildings, and in the distance one can make out the World Trade Center "Twin Towers."

The skyline at night. There's something I love about a city sitting on the water. (My good friend Josh would back me up here.)



So New York...where to start? I am looking forward to seeing friends who've promised they'll come visit. One of my favorite things about the city is its density--the fact that in midtown it's totally normal to be waiting with fifty people to cross the street. And the Juilliard School of Music is definitely a plus; I see myself catching many a recital and concert there.

But for now, we'll talk about the New York City Subways. If you've never been to the city, I think the subways are an integral part of the experience. They allow you to walk to nearly any place in Manhattan. And they expose you to the breadth and diversity of life in this metropolitan behemoth. A word of warning--personal space is more of an abstract idea than a reality. I remember riding during rush hour and realizing that I was touching no fewer than four strangers...and this was normal!

The MTA home page is full of information, but I've gleaned some impressive facts for your perusal.

• More people ride NYC trains than all other commuter trains and subways in the nation combined.
• An average of 7.7 million passengers ride the trains & subways every weekday in New York.
• The subway system annually uses enough power to light the city of Buffalo for a year.
• The fleet travels 347,188,000 miles per year. (Keep in mind that the sun is only 93,000,000 miles from the earth.) It would take light, traveling at the speed of light, 30 seconds to travel this far. Time would essentially slow to a standstill at these speeds.

Bonnie and Clyde

I'm sure that all will recognize this picture:

That's right. It's the hotel room in Columbus, OH, where George and Jennifer Hyatte were recently apprehended by police. (See today's www.cnn.com) I'm sure this one will go down in the annals of photojournalism. Notice the rumpled sheets, the cans of soda and bottled water on the nightstand. It's telling. These weren't just criminals. They were people. Like you and me, they also wondered what kind of free breakfast there'd be the next day; they worried, "How clean are these bedspreads?"

I wonder if they thought to leave a tip for the maid.

A not so hum-drum day...

...would give me plenty of material about which to write a post. Today, however, leaves me struggling to write something that merits the scrutiny of thousands of readers.

Despite my previous resolutions, I decided a 30-minute afternoon nap when I got home at 3:30 would be just the thing to recharge me for the rest of the day. Upon awakening, I was pleasantly surprised to see my friend Adam walk in the door. He, David, and I relaxed in the living room for an hour or so. Turns out my suspicions were correct, per Adam's report: Dave and Louisa are now engaged!!!

The rest of the evening was spent cooking some salmon for dinner, and then reading the New England Journal of Medicine at the library.

Maple-Bourbon Glazed Salmon with Dill Sauce
Mix one tablespoon bourbon with 1/2 cup maple syrup. Glaze a fillet of salmon for thirty minutes after rubbing with salt and pepper. Meanwhile soak a cedar plank in water for thirty minutes. Heat up the gril, and the fish on the plank for approx 25 minutes. Spread leftover glaze liberally over the salmon as it cooks.

For the sauce, mix 8 oz sour cream with 8 oz goat cheese, 1 tablespoon fresh dill, and freshly ground pepper. Spoon over the salmon and serve with lemon wedges.

Running in the rain

Another afternoon thunderstorm rained on the city today. Traffic crawled down the expressway on my way home, but fortunately I knew a little shortcut that bypassed a good 3/4 mile of traffic! And even though I'm post-call, I wasn't that tired, so I decided a quick afternoon run would be just the thing. Although it was nice not being drenched in sweat, being drenched in rain still leaves me drenched...

I had quite a few cross-cover calls during the night. One of the first one caught me in the dead of sleep, around 1:00 in the morning. "Doctor," the intense nurse began, speaking quickly, "the patient's Calcium Gluconate was written for 50 mg/hour, and the dilution leaves it at 1 mg/cc, but the fluid has been running in all day at 4.5 cc/hour, so should I run it as ordered at 45 cc/hour, or continue as it's been at 4.5 mg, could you please clarify?!?" I felt like I'd been awakened by a story problem: If a train leaves Chicago heading due east at 80 km/hour and 2 hours later another train leaves Pittsburg heading due west...

An hour later, another page came. This time, the ICU was calling. The nurse taking care of my intubated patient began explaining that his O2 saturation had been dropping and they were having trouble keeping it up. I was a little confused what his question was, until I asked, "Would it be helpful if I came down?" and he answered, "Yes!! Please do!" Even though this took nearly 45 minutes in the middle of the night, it was one of my first opportunities to work through a good differential diagnosis for shortness of breath in the acute setting. I ended up diuresing the patient for a volume overload state, but the lower extremity dopplers in the morning showed bilateral DVT's (deep venous thromboses), even though the patient is on prophylactic blood thinners. Even with my lack of experience and still young sense of intuition, it was satisfying to be able to take care of a patient simply by virtue of being there.

A little Beethoven...

Today was a much needed day off! (My last one was Thursday, July 21.) I enjoyed the luxury of sleeping in until 8:30 and even toyed with taking a morning nap. I'm still plowing through the Hawking book, but it's a little denser than I'd anticipated. Space-time, quarks, and anti-matter fill the pages. It's a little surprising, however, to read about the revolutionary ideas of Maxwell, Dalton, and Bohr in the 19th and 20th Centuries, and to recognize these names from various facts I'd learned for freshman Chemistry in college, eight years ago. This book sets the "Pauli Exclusion Principle" and the "Heisenberg Uncertainty Principle" in the context of the developing understanding of the world around us. Some things we now take for granted (like an atom's being composed of electrons orbiting around a nucleus made up of protons and neutrons) weren't always known. These discoveries were made little by little as speculative theories, experiment, and observation led to accepted fact.

This afternoon David, Dawn, Erin, and I got together at Erin's for round two of "Us verses Beethoven Razumovsky Quartet No. 1." We did a little better this time around! And I hate to admit it, but I'm enjoying the "middle part" nuances that I can create with the viola. While we rehearsed, a wonderful Texas summer thunderstorm rolled through which added greatly to the ambiance!

Another call day tomorrow. We'll see what it brings!

A "capped" call day

Another day admitting patients...since there are two interns on my team, there's a limit of 10 patients (five per intern) that can be admitted per call cycle. We reached that limit, or cap, at approximately 11:00 PM. My last patient is gone to ultrasound, so I'm killing a little time before she comes back so I can interview her. The attending physician has already seen her, so I've discussed the case with him and pretty much have her admit orders together.

Seems like a good mix of cases today. I've picked up:

1. Rule-out myocardial infarcation in an elderly Hispanic man.
2. Heat stroke verses infection in a white female (temp of 109.0), progressing to sepsis, shock, and disseminated intravascular coagulation
3. Acute arterial insufficiency in a middle-aged white female
4. Unilateral leg edema in a middle-aged white male
5. Acute on chronic lower back pain in a middle aged white female with fibromyalgia. Also with acute renal failure, elevated white blood cells, and elevated liver function tests.

It's now 1:30 AM and I've finally finished admitting and getting the patients "tucked in." If I'm fortunate I'll get four or five hours of sleep, and I hope to get few cross-cover calls during the night!!!

My reading list

As mentioned before, one of my little goals is to read a bit more. The last book I read for fun was back in June. Named The Curious Incident of the Dog in the Night by author Mark Haddon, this book provides an interesting glimpse into the mind of an autistic child. (More info here.) Having worked with autistic children himself, the author's insights and compassion are evident. Quirky illustrations and diagrams liberally sprinkle the pages, and prime--rather than sequential integral--numbers head each chapter. Amazon.com reviewers give strong marks to this book, and I too would recommend the book.

I picked up Stephen Hawking's ever-so-famous A Brief History of Time the other day. For those with the slightest bit of interest in reconciling the general theory of relativity with quantum mechanics, I'd recommend this book. And if you find anything with the word "quantum" daunting, I'd encourage you not to be intimidated by this book, because Hawking writes with laypeople in mind. Some say the true mark of genius is being able to explain complexities in a simple and straightforward manner. While I think that's silly, I still appreciate the author's ability to do just that. If you took physics in high school, that should be enough background.

Trivia time

After one month of residency, I've taken a little time to reassess. Today I sat down and made a list of things I'd like to do differently while in residency; e.g., do more anesthesia reading, exercise in the mornings more regularly, read daily about at least one of my patients, etc. That was one column. In the right-hand column, I listed how I might go about accomplishing each goal. And I think it all comes down to going to bed earlier! This will give me time in the mornings, as well as help me resist the temptation for a time-wasting afternoon nap.

A rather unpleasant experience awaited me in the ICU this morning. From across the nurse station, I heard an ICU attending make a demeaning comment about my TPN (Total Parenteral Nutrition) orders to another resident, not realizing I was at the nurse station. I walked over to him, and I think he felt embarrassed when he saw my name, but still was condescending and sarcastic when he questioned the electrolyte concentrations I'd ordered. Even though it was one of those situations where I felt he was acting inappropriately, I was pleased that I was able to respond calmly and professionally, and explain my rationale for ordering the TPN as I did. It turned out that my TPN orders would have made a lot of sense had not another MD changed some other orders after I'd rounded--orders I'd had no idea were changed. Anyway, I'm certain it won't be the last time that a superior is perhaps out of line, but at least it was good practice in keeping my cool in that type of situation.

I felt I redeemed myself in the ICU this afternoon when I successfully and essentially independently placed a subclavian central line with the supervision of my resident and a different ICU attending!

Here's the trivia question for the day: What was the largest thing killed by the first bomb the Allies dropped on Berlin in World War II? 10 points for the first correct response...