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...