Sunday, November 16, 2008

My first patient to die


I knew it would happen sooner or later. Everyone eventually has a patient die. I'm sure other patients of mine had died before, but this is the first one I knew about. She had serious emphysema. You get that from smoking.

Anyways, she came in for an exacerbation of her emphysema. She could hardly breathe. And she was only 50 years old. We gave her breathing treatments. A chest X-ray suggested pneumonia. That would explain why she suddenly had trouble breathing. We treated her with antibiotics. She got better for a while.


The trouble with antibiotics is this: They wipe out ALL bacteria. This leaves room for bad ones to grow in the place of good ones. We all have C. difficile in our colons, but when you wipe out all of your normal bacteria, C. difficile can overrun everything. And the result is horrible diarrhea. Most people get over it.

But in some peple, this diarrhea progresses to something worse. She developed "Toxic Megacolon," where the gut simply is overwhealmed with the bacteria and ceases to function. This bacteria got into her bloodstream. The only option was to surgically remove part of her colon. However, she was in such bad shape that her mortality from this procedure was 100%. And without the procedure, it was 100%. There was nothing we could do, except let her die. And that is what she did, after a few hours.

I plan on going to the autopsy tomorrow. It seems right to see everything through till the last steps. The permanence of it all is stifling. From joking about her kids just a few days ago.... to this. I hope she did not suffer too much through it all.

My Backpack

I'm going to Portugal in about a month. I always travel with my large camping backpack, a trusty REI Valhalla. I first got it in the 8th grade, when I figured it would be easier to carry everything with me rather than keep going to my locker. Other kids called it my "body bag" and suspected that there might be some dead person deep in there. After all, it was about as big as I was at the time.
However, after 12 years of service, it didn't look quite up to the trip. The stitching on the bottom was starting to come apart, and the waterproofing on the inside was flaking everywhere.
I remembered that REI has a 100% satisfaction guarantee. So I put it in the car and drove to a nearby store. I went to the customer service counter. The man was very nice, but he couldn't find the bag in his computer system (it was too old). So after a bit of discussion, he offered me a $60.00 credit. Sounded fair to me.
Then I went backpack shopping in the store. The salesman was very helpful, but when I inquired about one of the packs, he said, "Oh, no way. If you think a 12 year old bag is returnable, that won't be nearly tough enough for you!" Point taken.
So I shelled out a hundred bucks on a Kelty Coyote 4900. Hopefully it will last me many more years. And it too has a lifetime warranty! I'm keeping the receipt though.
But right now I'm really missing that purple REI bag. It went to school with me for years. Countless camping trips. Probably 10 times across the Atlantic. London, Paris, Rome, Nice, Naples, Avignon, Cambridge, Frankfurt, Montreal..... I kind of want to drive back to the store right now and get it back. Maybe I can sew it back together.

Monday, September 15, 2008

I become the patient

I came out of the shower and dried myself with a huge white towel. Something caught my eye. What was that on my back? It was dark, but I couldn't get a good look at it, even with all the mirrors in my bathroom. I'd never noticed it before.

A few days later, I became more worried. Could it be the dreaded melanoma? I had recently seen several patients die of metastatic melanoma in the hospital, and they were terrible, slow, painful deaths. I was rather young for such a thing, and I tend to wear sunscreen and keep out of the sun when I can. But there was still a chance. And if it was the real deal, catching it early was my only hope. If it invades more than 1 millimeter into my skin, my five year survival (the odds that I would live longer than five years) drops off a cliff. I couldn't let this go.

Since I couldn't see it well, I took pictures of it with my digital camera. I saw that it met all the ABCD's of melanoma. It was Asymmetric. Its Border was ragged. It was comprised of two or more different Colors. And its Diameter was greater than a pencil eraser. Shit. This could be bad. Should have used more sunscreen. I suddenly remembered the blistering sunburns of my youth. That time in Saudi Arabia when my skin was peeling right off my back. All those times I went water-skiing without sunscreen. Those blistering sunburn drastically increase your odds of skin cancer.

So I went to the Dermatology department to try to make an appointment. They asked to see my insurance card. Then they told me that the first available appointment was in late November. Really? I'm supposed to wait more than two months with a time bomb on my back?

That afternoon, I decided to take matters into my own hands. I would not wait that long if I could help it. I left the pediatric neurology clinic in which I was working, and headed towards the derm clinic. I tracked down the doctor I was after, and introduced myself. "Hi Dr. B! I'm me. You worked with my dad a while back. I have this thing on my back, and I think it might be a melanoma."

He was so nice. He immediately took me into a room so he could look at it. He thought it was suspicious, so a few minutes later, he took a biopsy of it. He asked for my pager number so he could give me the results as soon as he read the slides (he's also a dermatopathologist). Now I have quite a few stitches in my back, but at least I know that I, and the little piece of my back, are in good hands.

Monday, September 8, 2008

The Nile

A patient comes in today. Middle-aged man, slightly balding. He had headaches that just wouldn't go away. So we got a MRI of his brain. The official report hadn't come in yet, but the images were on the computer. So I glanced through them.

MRI is an amazing thing. With the click of my mouse, I can fly through cross sections of a person's brain, seeing it in exquisite detail. I can see, millimeter by millimeter, what makes you who you are.

As I flew through the cross sections, I started to see bright spots at the junction of the gray and white matter. There were ar least four to my untrained eye. I called over the resident (a junior doctor). He agreed. Lesions at the gray-white interface are pathognomonic for metastatic cancer. The patient's prognosis was dismal.

The resident and I went into the patient's room to tell him the news. His wife was there.

"The results of the MRI are not good," the resident told him. "We think you have cancer in your brain. The prognosis is not good."

He looked at us for a while, not showing much emotion. I tried to picture myself in his position, but couldn't. I had no idea what I would do or say or think.

He said, "Jesus will heal me!" "I'll be fine, 'cause Jesus will heal me!"



Denial ain't just a river in Egypt.
-Mark Twain

Crazy People

Mr. T came to the hospital to detox for his sixth time, and he was only 25 years old. He was taking large amounts of Valium, booze, and opiates, as usual. So we detoxed him, giving him meds that would make him more comfortable while he withdrew from the drugs.

He would come up to me, seemingly from nowhere, and beg for more. He said the withdrawl was unbearable. He hadn't slept for days. He was anxious. He was sweating. He felt like he was crawling out of his skin.

And then he started to pee blood. A lot of blood. Oh shit. And on top of that, he had a urinary tract infection. He had a history of kidney stones, which can cause bloody urine as they pass through. And he described in perfect detail the exact location and excrutiating pain a kidney stone can cause.

He wanted opiates for his pain. If it were anyone else, we would have given it to him.

So we got a consult from Nephrology. They said that the bacterium cultured from his urine usually didn't cause UTI's. We started him on antibiotics. A CT scan confirmed that there were stones in his kidneys, but unless the stones actually pass through, they shouldn't cause any pain.

Then we got a Urology consult. They said his bloody urine was almost certainly due to "self manipulation." This translates to him shoving a coat hanger into his penis, all the way through his urethra, and then into his bladder, and then whirling it around. All to get opiates.

We discharged him a few days later. He was supposed to go to an inpatient drug treatment program the very next day (we had set up everything for him). But he relapsed, again, and nearly died, again. So now he's detoxing at yet another hospital.

At first I was furious. Furious that he had misled us. That we had wasted thousands of dollars for needless tests and consults. Money that could have probably saved several lives elsewhere in the world. All because this idiot was a druggie.

And then I felt sorry for him. Genuinely sorry. I wondered how a person would have to feel to do such a thing. To fake kidney stones with a coat hanger just to get some drugs. Never before had I realized the power of addiction could be so strong. So strong as to take over everything that you have been, or ever will be.

Friday, August 22, 2008

Death

The thought of death is terrifying to me. You would think, being a medical student, that it would be natural... In some ways it is. But in almost all ways it's not. The permanance. The feeling of never feeling anything ever again. The emptyness. The abscence of anything. That scares me. I will be zero. Just a memory in someone's mind.
It really came home today when one of my professors, in Neurology, said it quite plainly: We are only future cadavers.
In many ways, I had only dealt with death superficially. It happened to other people. My job is to help prevent it, or if I can't, I am to make it as comfortable and palatable as possible.
Now I understand why people want children so badly. It is their way of cheating death. The one way of outliving one's self.
But still I can hardly imagine myself dead. The stagnation of it all. I would think it boring, but that implies consciousness. I can only hope that the purpose of my life is to provide comfort to those who need it the most. To those who have nothing else. To those who know the end is near.

Sunday, July 13, 2008

Coxing while intoxicated?

So this saturday, I got up at 6 in the morning so I could be rowing at 7. The only problem is that our coxswain was half an hour late. Her mom dropped her off at the lake. She said she was really sorry, and that she had had a late night (going to bed at 5 in the morning to be exact). She said she was still drunk from the night before, after having quite a few drinks with her friends. And from the way she coxed the boat, she still clearly was. The smell of vodka on her breath was still strong. We joked weather she could get in trouble for coxing while drunk. But all was good, and we had a good row, even if I got quite sunburned in the process.

I spent most of last night and this morning figuring out how to replace the battery in the cox box (the thing that amplifys the coxsain's voice). I went to wal mart and found some RC car batteries, which were perfect (600 Mah NI-CD's). After a lot of soldering, the cox box is working again. Yay for saving a few hundred bucks.

Friday, July 11, 2008

So much has happened

So I spent this summer in England, studying for Step I of the NBME examination (the first step to becoming a licensed physician). This was probably not the best decision I've ever made, since there were plenty of distractions and other stuff to do.

We went to the Isle of Man for a vacation. This cost a fortune (as everything does when the dollar is so weak) but it was well worth it. We stayed at the Wicklow Hills hotel, which is within a half hour walk of the ferry terminal. A guy was waiting outside, and greeted us as we walked up to the place (at 1 in the morning). "Mr. and Mrs. XXXXXX? Welcome to the wicklow hills!" He showed us to our room, and told us that we could arrange payment the next day. Fucking amazing service.

Wednesday, July 9, 2008

Wow, so much has happened since I last posted. I went to England to study for my step I board exams, and that seemed to go fairly well. While in England, I went to the Isle of Man, went to the Cambridge Beer festival, got chased down an alley by a drunk guy bent on hurting me, and had a jolly good time overall.

I got back to the US. I studied a lot. I took the boards exam, and think I did ok. And now I'm starting the third year of med school.

Wow, I'm half of a doctor already. Who would have known?

Thursday, April 3, 2008

MedWars

So let me tell you about MedWars. It's an adventure race with a medical theme to it. This year it was held in Augusta, Georgia at an army fort there.

We left Nashville an hour late because V screwed up her schedule. We got there late, but I slept like a log on my wonderful thermarest.

The next morning, we registered and got everything ready. V hadn't brought a pack with her, but by some miracle, I decided to bring two, just in case I wanted to use a larger one. Then I saw V in jeans. She was the only one there with jeans on. I tried to get her to put on my spare north face pants (which would have fit her fine) but she refused. "If my jeans get wet, I'll put on my other pair of jeans!"

The race started at 11 AM. We got slightly lost, but not too bad. Three hours in, we had to cross a swamp - and the only way across was to wade (swim) through. I was up to my neck in water (and I'm 6' 2") and decided it would be easier to swin than to try to keep my pack dry by holding it over my head.

Afterwards, V changed into her spare jeans. I simply took off my shirt and hopped around to keep warm.

And then it started to pour. And it got much colder - into the 50's. V forgot to bring a jacket. All she had were her soaking wet jeans and a tank top. I gave her my jacket to keep her from serious hypothermia.

And then her hip started hurting. She walked slowly, and would sometimes simply stop and sit on the side of the trail. I ran in place to try to keep warm. At this point, I was shivering constantly.

At the last checkpoint, me missed the time cutoff my 15 minutes, and were disqualified. It continued to rain constantly. We walked back to the campsite. The tents were soaked. M had no clothes, so I put her in my car and warmed it up. My hands had trouble gripping anything.

And after 7 hours of driving, we were finally home, and I got to bed at 3:30 in the morning.

Tuesday, March 25, 2008

Purgatory?

I was talking with a few med school friends the other day. One had just recently gotten divorced after six months, because his wife was a giant bitch (anyone could have told him that). He said "I think I need to find a new church." I said, "What do you need a church for; it will just cost you time and money."

The girl in the group scoffed. Like I had said something heretical.

The conversation went on from there. The girl said how her grandmother kept a bottle of holy water with her, and splashed it on every kid she saw so they would not have to go to purgatory.

I said, "I thought they got rid of purgatory."

She said, "I guess she didn't get the message."

Saturday, March 8, 2008

Music

Have you ever discovered a new song on your computer, one that you had never heard before? Has it brought you joy - a feeling of happiness and euphoria that you haven't felt in a long time.

This happened to me today. "Prize Fighter" by The Velvet Teen popped up on Itune's Party Shuffle. I have not been the same since.

Thursday, February 21, 2008

Ambulance

I’m riding in the “box” of the ambulance. There’s a call for a 80 year old African American woman with "seizures." Doesn't sound too serious. Besides, an ALS (advanced life support) fire engine is on the way, well before we will get there.

Mid-way there, the driver yells back into the box "they're doing CPR." The driving gets noticeably more serious. We're running red lights like crazy now. Oh boy.

I rehearse what I learned over a year ago in my head. 30 compressions and 2 breaths. Or is it 30 and 4?

We arrive at the scene. The patient is lying on the floor, with a tube into her lungs. Someone is performing chest compressions. A woman cries in the corner. Another man looks forward, blankly, as if nothing is registering at all.

I see a big bottle of oxygen in the corner of the room, as well as a peak flow meter. She must have lung problems.

The paramedics flop her onto the blue backboard. They struggle to keep her lifeless hands from flopping to the side. Someone instructs me to turn the stretcher around, which I do. They place her onto the stretcher. The paramedic I'm with points to me and says "Start chest compressions!" I do. They load her into the ambulance with me compressing away. "Use the heel of your hand! Harder!" I continue compressions for about five minutes until someone else takes over. I’m exhausted. I could feel that some of her ribs had broken (not unusual). And there's no discernable heartbeat pattern on the monitor.

I hand someone a stethoscope. No left lung sounds. Must be a right mainstem intubation. They pull out the tube a bit, and it sounds better. They give her epinepherine and atropine through a needle in her neck. Someone asks me "Do you feel a femoral pulse?" I reach down there. "Um, maybe, yeah, I think so." Indeed, she now had a (slow) palpable pulse. God Damn, I was sure she was going to die. Wow. We saved her!

We arrive at the ER. The doctor looks none too pleased. He asks "how long has she been down?" "About 10 or 15 minutes, but she has a pulse." "Damnit! Well, resume chest compressions, then. We have no critical care beds!"

In any event, she will probably never leave the hospital.

Tuesday, February 12, 2008

ER tonight

Radio says kid was shot in neck, point blank. Five minutes out. I'm there in the trauma bay, expecting the worst. He must be dead or close to dead. They wheel him in. I'm in full protective equipment, wearing what amounts to a garbage bag and face shield to protect me from flying bodily fluids.

The EMT asks him if he can move over onto the other gurney. WTF? He's conscious?

They examine him all over and take X-Ray films.

He's fine. The wounds are mostly superficial. The bullet is still lodged in his arm, though. To make it from the neck to the arm without hitting anything important is incredible. No one could believe it. If only everyone could be so lucky.

Plastic Surgery

We went into the examination room. A woman was confortably sitting in a chair. I silently thought that she probably wanted a face lift or some such thing, even though she looked fine. This is plastic surgery after all.

How wrong I was. Ten yers ago she was in a car wreck, without a seat belt, and her face was smashed to pieces (the so-called pan-facial fracture). With some surgical wizardry, the plastic surgeon made everything look PERFECTLY NORMAL, at least to me. He still says that her maxilla is a little bit too big. Her only problem that day was that her nose itched a bit.

Damn. The thought that with your knife and skill you can make something look like it never happened. To give someone back their life, free of shame, free of self-consciousness and embarassment. Amazing.

Saturday, February 2, 2008

John McCain


I've never been to a political rally before, so I thought I would at least make the effort to walk across the street to my old highschool's gymnasium.

I got there half an hour early. Plenty of people were already there. A woman offered me a McCain sticker, which I affixed to my coat so I would blend in better. "This is my country" was blaring from the speakers by the stage. The backdrop was a huge American flag. I didn't see a single black or hispanic or asian person.

Interestingly, there was NO visible security. None. You would think they would at least check people for guns, especially for a guy who is about to be the Republican presidential nominee.




There were three throat-clearing speeches before McCain took the stage. One guy talked about how he took Sadam Heussein's blood pressure after Saddam was captured. Another read a poem about Tennessee, written buy a POW in the Hanoi Hilton who was in the cell next to McCain's. McCain's wife talked about the daughter she adopted without her husband's knowledge.

"Where's she going to go?"
"I thought she could stay with us, dear."
"Oh, Ok."

Then there was the pledge of allegiance. And then the national anthem.

And then McCain finally took the stage with a huge cheer erupting from the crowd. Cameras flashed from every direction.

He gave his well-rehersed stump speech. Promised to find Osama. Promised to make Bush's tax cuts permanent (I had to concentrate to keep my groans from being audible). Promised to reign in federal spending using the "veto pen that Reagan gave me." Promised to give better healthcare to veterans.


And then he walked into the crowd with his wife, and was immediately swarmed by people wanting an autograph or wanting to shake his hand or wanting a better picture.

It's too bad McCain is a Republican. He would probably make a great president if he weren't so beholden to the conservative right.

Wednesday, January 30, 2008

The thrill remains

Hey L. You still owe me a dollar, don't you?

No, I gave you your dollar last Wednesday. You don't remember?

Oh. Well, I'll give you back that dollar if you go to Cadaver Prom with me...

Oh. Ok. Well, I'm watching a movie right now.

Ok.

I'll call you back.

I'm going to sleep in an hour, so make your movie quick."

L. calls back, and says YES, to my amazement!

Saturday, January 26, 2008

Launry Detergent Thief

Two months ago, I realized that someone was stealing the laundry detergent that I keep in the communal laundry room. Every week, another three loads' worth of detergent would disappear. My half-full bottle would be nearly empty when I needed to use it. So before I left for Italy, I took the nearly empty bottle of Tide Free and filled it up with vegetable oil. Looks exactly the same. That'll teach them.

When I got back, I was shocked to discover that 1/3 of the bottle was gone. This means that the person did MANY (like 8) loads with vegetable oil. They didn't notice something different about their clothes?

I filled up the bottle again with more vegetable oil. And when I checked it a few weeks later - the same thing. WTF?

I'm not sure if I should just keep filling up the bottle with vegetable oil, or if I should write on the bottle "You've been washing your clothes in vegetable oil for the last two months, you detergent-stealing asshole!" Thoughts?

Tuesday, January 22, 2008

Pro-Choice Rally

Today is the 35th anniversary of Roe v. Wade. There's one student in my class, Student L, who is very active with Medical Students for Choice. In the hall today, she persuaded me to attend a rally that abortion rights proponents were having later in the day. At first I was non-committal, but finally agreed to (she's kind of cute).

So I showed up wearing my white coat. It was drizzling out and slightly above freezing. I was expecting a stage with a speaker and a bunch of people cheering. A rally, right? Wrong.

They were standing on the busiest street in town. As I approached, someone handed me a sign (I held the Roe part of the Roe v. Wade HONK!" sign complex). A woman advised me to stand as close to the curb as possible because anti-abortionists would probably come and try to stand in front of us. So I stood there, holding my sign and waving a flag every time someone honked, which was not that often in the Bible Belt. A woman came up to me and asked if I would be willing to be interviewed by News Channel 4. Sure, I said. More people showed up. My gloveless hands were already numb. The drizzle intensified.

Student L as well as several other med students (including Student E) finally showed up, 20 minutes late. Making their signs had taken longer than expected.

Only a few anti-abortionists showed up. One guy stood behind me (I was right next to the curb), and constantly muttered something about the "value of life."

There were plenty of honks after a while. All (maybe 40) of us formed a line on the curb that was hard to ignore. One passenger in a car leaned over to honk the horn, causing the car to swerve. Another minivan drove by, all six kids emphatically giving us the thumbs down. Guess the parents didn't use birth control.

Student L asked me "Do you really think we're actually accomplishing anything?" "No," I said. "We're probably just pissing off the religious folk."

"Yeah, you're right," she said. "But that's ok by me."

"Me too... Me too."

Ears, Nose, and Throat

The doctor looked into the medical student's ear. "Too much ear wax." She looked into the other ear. "Wow, even more wax! Who else wants to volunteer to be the patient?"

I rose my hand, sat down in the chair, and the doctor inserted the otoscope. "Beautiful tympanic membrane with almost no wax. Your ear canal is unusually straight. Ought to be perfect for demonstrating."

"Q-tip every morning" I said. "That's probably not the greatest idea" she responded.

Student E grabbed the otoscope, peered in, and said she saw the eardrum. Mission accomplished.

Student L then took the scope. She couldn't see anything, so her solution was to insert the scope farther with a quick jabbing motion, which evoked a sharp yelp from me. She appologized profusely.

Then it was off to the nose. The doctor inserted the speculum and peered in. "Hmm, slight deviation of the nasal septum to the right. Now you guys take a look. Just remember NOT to close the speculum before removing it, or you'll take out some hairs."

Student L took a look without complication. Then student Y did, but apparently forgot the doctor's instructions in the intervening 30 seconds. He closed the speculum while taking it out, taking five nose hairs with him. You could see them still attached to the speculum.

"Owww! Goddamnit" was my reaction. My right eye started watering. Student Y appologized profusely and got me a tissue.

I asked the doctor why pulling nose hairs caused tearing.

"It's called pain" she responded.

Saturday, January 19, 2008

Natchez Trace



Today I drove to the natchez trace and took a few photos. It was bitterly cold, especially on the bridge with the blowing wind. Normally I would have ridden my bicycle there, but it was just too cold today. Then I drove to Wal-Mart to buy some 3X5" index cards to study pharmacology.

Earlier today was parent's weekend at school. My parents and I got there at 7:45. I'll bet the school spent well over 100K on everything. There was a huge tent, zillions of servers, wonderful food, a lot of speeches, etc. The highlight was the "organ recital" that the pathology professors put together for the parents. They were shown lungs, kidneys, hearts, etc., all with varying stages of diseases. Tonight is a dinner for everyone, which I won't be going to since my parents can't make it.

Friday, January 18, 2008

Standardized Patients

I was walking out the door when I ran into my psychiatrist neighbor. I said "I'm going to interview a standardized patient today!" He said "what's a standardized patient?" I was a little surprised. I said "It's an actor who's paid to pretend to be a real patient. We get to practice on him." He said, "I my day, we just interviewed real patients. There's plenty at the mental health cooperative that would be jumping at the chance to get interviewed for 15 bucks an hour." Hmm.

So I left for school. The patient was a 40 year old man. The presentation was so classic I almost started laughing. Unilateral headache, "shimmering" visual aura, slowly progressing, pounding pain, lasting about a day. Nausea.

A migraine headache. Case solved. I reassured him that he didn't have a brain tumor, which he was worried about. It was kind of thrilling actually. Putting all that I knew together and making a diagnosis, even though it was a fake patient. I even knew how he should be treated.

Hopefully the next one will be more challenging.

Tuesday, January 15, 2008

Standardized Patients

Today I had my first encounter with a standardized patients. These people are actors who are paid to simulate real patients. They are given a list of symptoms, and act like real patients while we interview them. The first was depressed, the second had classical angina, and the third had carpel tunnel syndrome. It's great that we can interview these patients and hone our skills without actually having to deal with any real patients. If we screw up, it won't actually mean anything. Plus they can give us feedback on how we did.

Today I spent three and a half hours in the gym. I did cardio, lifted with Kam, and then played squash with him for a long time. He and I are almost perfectly matched.