Chronicles of a Medical Mad House.

Doctor

2006-02-02T23:09:00.000-05:00

If you are seeing this then you are in the wrong blog. Come to my new blog called Doctor.

The Chronicles have come to an End

2006-01-04T16:21:00.000-05:00

I can be found in my new home. Welcome to Doctor.

Ruined by Reality

2006-01-03T20:20:00.000-05:00

Was that me, dressed up in a dark suit doing my best not to look intimidated?

Three years have changed and these fourth year students filing into our conference room remind me of a younger self. How they shine bright with curiosity for answers only their future will tell. The prospect of a career in medicine is exciting for them now. It is the beginning of a new world. Everything, it was all for this. Again, with another September starts another match.

It is that time of year again, when a competition ensues to capture the most valuable of prizes, a medicine residency in a prestigious institution. There are only a handful of these and that makes each and every position precious. Each of these students knows it will be a critical steppingstone to a future glorious career, and so did I.

I had survived a breakup with my fiancé, struggled through four years of medical school in a foreign country, even found the love of my life while there and got married. I came to the Mad House is 2002 anticipating a day of sweating and squirming as I attempt to guess the most desired answer. I had the future in my hands, they wanted me, and the prospect of a career as an internal medicine doctor was exhilarating. I remember running home to tell my wife that I was offered a position, hardly able to contain myself.

So what happened?

That young man and this seasoned resident, they are such different people. In between them three years of an internal medicine residency that drove that same young man on a path to…well, you read this blog don’t you?

Unfortunately, the real world happened.

Saving a troubled father of two from a severe bout of congestive heart failure was rousing. Saving that same father from another bout and yet another simply because he refuses to take medications can be downright depressing. They say memory is selective, I find mine tends to select for depressing moments.

This is one of the reasons I never delete negative comments. They ground me. Often, they allow me to reflect on the true magnitude of what it is that we do. Somewhere and sometimes I make a difference. And that is essentially one of the greatest things anyone can do. But I’ve lost a large part of my former compassionate self.

At times though, I do miss that young fourth year. Would he disapprove of what he has become, a new breed of healer and warrior struggling with himself to survive?

Reading this you probably think my patients don’t appreciate my efforts. But, my patients actually do like me. I know you wouldn’t think so from reading this blog but judging from the comments and gifts I get at my clinic, they must.

So to all the fourth year students who have that jazz in their step, bouncing on clouds, hoping to high-heaven they do well. I wish you all the best. Moreover, I wish you the wisdom to know that what you are doing, as depressing and downright useless as it may sometime feel, is immeasurable good, even if your patients don’t know it.

Like well trained warriors, don’t let your compassion run dry, but do learn with who it’s worth fighting your battles.

Future Intern Wishes You a Happy New Year

2005-12-30T16:33:00.000-05:00

From inside my investigational lab where I can assure you we are making progress in the ultimate battle against some of the worlds’ greatest health threats, I wish you a Happy and Healthy 2006.

First order of business, this new anti-madhousemadman antibody. That should save a few thousand from that internal medicine doctor.

Carnivals

2005-12-28T12:04:00.001-05:00

Grand Rounds is here.

COTV here

Bonfire of Vanities here.

Merry Christmas and Happy Chanukah

2005-12-23T23:02:00.000-05:00

As 2005 winds down I am once again amazed at how fast goes the passage of time.

There is a sign posted on the stall room door in the Mad House. It reads “They can always hurt you more but they can’t stop time”. It’s a grim reminder of how demanding and grueling this job can be both physically and emotionally, it’s also derogatory. Such as the resident who complains of the patient who “dropped his pressure on me”, as if it was something he was consciously in control of. It’s like this blog, mis-directed anger written in a comical and sarcastic fashion.

One year and four months later I am still writing. This blog has allowed me to vent my anger and my frustrations. It has been a medium through which I have been able to connect with some of my readers and establish new friends. And it has allowed me to write, something I enjoy. Also, I was able to share with you my experience of an internal medicine doctor. It is something I will be able to reflect upon later on.

The holidays are upon us. Christmas is here. I am late with my warm wishes but that has never stopped me before.

It’s been an opportunity to read up on what I’ve written over the last year. I thought of including a top ten list. Reading some of the entries I was amused at my sense of humor. It’s not too bad, wouldn’t you say? I can write too. No wonder you read this blog.

Reflecting upon my blog is sort of funny. I was able to review some of my insane attempts at gathering readership. These included, but are not limited to, my blog parodies and my Gray’s anatomy reviews. They were entertaining but exhausting and I will never commit to staying up until 11 pm on a regular basis, during a medical residency, again.

But there was more. Remember the traveling story, or the introduction of the Madman that stands above, or the one before him.

I realized that during summer I shouldn’t write. For one, I don’t feel like it (During August I had two entries, both two lines long) and also I don’t write well when I want to get out.

But for now I will continue writing. Because I love to.

Mad House Top 10 of 2005: (as chosen by the Mad House Madman)

Recommendations for Personal Statements
A guide to AMA. And follow up.
Room 422
Problem Solved
CD4
Gotcha
Spectrum
PTT
A Small Percentage
Dangerous, Do Not Touch

And of course not a post, but, by far this is my most favorite entry this year.

Most of the wonderful comments you guys made have been erased by my attempts with Blogger/Haloscan/blogger. I'm sorry for that.

Merry Christmas to everyone and a Happy and Healthy New Year.

COTV

2005-12-21T11:17:00.001-05:00

chekc out the COTV at Ravenwood's Universe

Grand Rounds

2005-12-20T06:53:00.000-05:00

I've officially requested to host Grand Rounds again but until Nick approves my request you'll just have to go enjoy them somewhere else. Today, Medpundit, one of our first medical bloggers has the honors.

Unpeople Person

2005-12-19T21:51:00.000-05:00

I find it troubling that almost all the fourth year graduating students in our affiliated medical school have no intention of entering primary care, or for that matter, internal medicine. What’s more alarming is the reason that they most often cite: “I found out I really hate to deal with patients/people”.

“So it’s not the money?” I ask.

Of course, it’s also the money, or lack thereof. Is it me or does the general trend go something like Jerry McGwire:

“Show me the money!”

I’ve heard so many lame excuses as to the sudden un-popularity of primary care among US graduates. Everything from blaming the medical schools for not promoting the specialty enough to citing residents for not making it exciting. Let’s cut the crap, bring some of the money back and watch how fast these graduates become people friendly again.

Haloscan Out

2005-12-19T20:02:00.000-05:00

I am contemplating getting rid of haloscan and going back to good old blogger comments. I just have to figure out how to un-install.

Of course this means that a lot of comments will disappear, never to be seen again. Sorry guys, I can't stand this haloscan thing any more.

Too Many Ways to Die

2005-12-16T06:08:00.000-05:00

Over the last three years I’ve developed a not so healthy case of generalized anxiety. It’s official; there are too many ways to die. Six million may be just a small exaggeration, but the point being: I know way too many of them now.

It seems I can invoke three climactic death scenes for anyone I know. You name a medical condition and I can think of ten horrible terminal scenarios that will part one with dear life. Diabetes, for example, causes complications ranging from a simple hyperglycemic coma to Diabetic Ketoacidosis, both potentially deadly. Even as I write the prescription for diabetic medications my mind trembles with fear at the thoughts of further potential complications.

“We tried to save him Dear Internal Medicine Doctor, but when we got there he had blood glucose of 10. By the time we finally got access it was negative 50.”

While most drivers worry about a high speed crash switching lanes on an interstate highway at 60 MPH, I worry about the driver in front suddenly having a tonic-clonic seizure. In a word, I find this new diversion “unhealthy”.

No one can accuse me of lacking imagination, or hypocrisy; after all, I’ve all but terminated myself a hundred thousand times over. I figure if things go well I’ll die of septic shock while my wife tries to urgently call paramedics. God will support my cause and due to unexplained reasons the four tires on the ambulance will go flat. I plan on having my jaw wired to prevent myself from being intubated, just for giggles. Maybe I’ll tattoo “DNR” on my forehead.

Of course, I’m anxious things won’t go as planned and I’ll get in the line of a perfectly good bullet, meant for someone else, on my way to an anti-gun rally. Each scenario just keeps getting more and more sarcastic and ironic, not to mention painful.

The next young man who complains of being abducted by aliens on his way to Pluto will surely get a STAT ride to psychiatry on my ER shift. It’s just that next time I may do one of two other things. First, I may congratulate him on a death scenario that even I could not have fathomed for such a healthy young soul. But in addition to doing this I may just ask him to “scoot on over” and make a little room for me on the stretcher. I think I need to come along for the ride.

Chalk another one up for the ER- Wait, I have to vomit first

2005-12-13T13:58:00.000-05:00

Its moments like these that made me want to become a doctor in the first place. The strange thing about all this is how these rare moments happen whenever I’m doing my ER rotations. Strange, because I find I am able to spend very little time with patients, much less than I would as an internist, and yet there are these little sparkles of light. Maybe this is what draws emergency physicians to their specialty. Although, I’m betting it’s the fact that they get to intubate.

I’ll set the stage. It’s five in the afternoon and I’m preparing to draw blood on one of my patients when the receptionist pages overhead “Medical notification is HERE!”. Normally, a notification is announced minutes in advance thus notifying the physicians of the severity of a particular case that is on its way to the Emergency department. This notification was slightly late.

Suddenly, I see a young girl; about 26 years old, being wheeled towards the back while Emergency technicians are trying to give her oxygen with a bag. She is not moving any air. I can’t hear any breath sounds. No time to react. We establish a line and she is intubated almost immediately.

After the intubation a careful exam still reveals clear breath sounds, no wheezing, normal peak pressures on the ventilator. While before the intubation this was likely a case of horrible asthma, it doesn’t seem to be the case now.

A further probe into her past reveals this patient suffering of a condition called paradoxical vocal cord movement. A cause was not yet found but is probably psychiatric in nature.

She is extubated one hour later.

Now she begins to wheeze heavily and we re-assess our initial impression.

She spends the next four hours wheezing heavily, looking like she needs to be re-intubated. But, all the blood gases and the monitor shows she is oxygenating perfectly. I think I may be going on too much about this case but here’s why I decided to write about it.

Before my shift was about to end I went to check on her. Having looked to me like she was tiring I decided to attempt another blood gas. While I was obtaining the test I started asking her about her life.

“I have four kids” she said.
“Four kids?” I answered, surprised. “If I had four kids I would be here getting intubated every night”. She laughed.
“Where’s your husband?”
“At home with the kids”
“How are things at home?”
“They’re great she answered” She was calming down. No more wheezing.
“Are you sure?” I continued.

And she nodded. We continued our conversation. I was trying to make as many jokes as I could, this was definitely working.

Within two minutes even the non-rebreather was off, the legs were crossed and we were having a nice little chat. No more wheezing.

“What causes this I asked her?” She didn’t know. She’s been to therapy, is on medication and still she’s been intubated five times. We talked for a while, no wheezing, no intubation, no blood gas. Just words. She began to breath normally because we were talking.

I went home happy that night. And that’s why I became a doctor.

This week's Rounds

2005-12-13T13:57:00.000-05:00

Go check out the best medical writing of the week.

Grand Rounds

2005-12-06T06:57:00.000-05:00

This week's Grand rounds are at the Examining Room. Charles has been doing so many carnivals you'd think he put a picture of a ferris wheel somewhere on the page.

Hail To The Chief

2005-12-04T18:28:00.000-05:00

Two days into my rotation as ER chief. That means that every patient who walks/is wheeled into the Emergency Room has to be seen by me first and then I hand it out to a junior resident.

“What part of Emergency did you not understand?”

Shame on you! You probably tuned in to hear me bitch about how bad Emergency Medicine is. Me, complain about the Emergency Room? You must’ve been reading another blog. Now wait here while I go fetch this guy a clean catch, I need urine.

“This is a level 1 trauma center. What level would you rate your arthritis pain and do you believe it really belongs here?”

I walk into another room as the twenty year old patient in the paper gown informs me I should remain quiet. “We’re in grave danger” he says. “I need a one-to one here” I announce to one and all as I storm out of the room to intubate the asthma exacerbation next door. Figures! He suffered blueberry poisoning last month and his parents tried to have him killed, in Europe, when they found out he was a double agent for the Israeli’s.

“I say Mazal Tov my dear friend. Please don’t let the door hit you on the way to the Psych ER” “And stay away from those blueberries”

The first day I was ill prepared. Guess what? It can get pretty busy here. Handoff rounds were of the brutal/ugly variety as I try to remember who these patients are, why they came and how old were they. I went with a ballpark figure.

“Senior citizen man here for pain in the abdomen”, “No, I have no idea, ask the junior what he found.”

The shift was over. I felt like I’ve been raped. Yes, I know this isn’t funny.

“Let me introduce you to the medical clinic. Sorry you waited so long in the waiting room but you see this building next door? You could have seen a doctor there ten hours ago in walk-in.”

Why the long-face? Did you not appreciate the Lumbar Puncture I did for your perfect tension-headache?

I love Emergency Medicine.

Grand Rounds

2005-11-29T14:15:00.001-05:00

Tomorrow I start ER chief. That's right, you guessed it, that means there's going to be a lot of ER bitching going on really soon. So while I get worked up why don't you go enjoy this week's Grand Rounds.

Dear Bluedude Please Consider This

2005-11-25T09:25:00.000-05:00

Recently, I wrote a post about being names in a lawsuit which was brought forth by a patient I had cared for in the past. The patient had a bad outcome and felt that this was due to the medical care he/she recieved or did not recieve. I've written similar posts about others before and usually what happens is that a med-mal discussion begins to brew in the comment section. It did this time as well and I put an end to it early, honestly, because I'm tired of hearing about it and arguing about it.

So why am I writing this post? Well, I've observed that the readers who are drawn to medical blogs are either people in the field or patients who have chronic disease and do a lot of research on the web about their own disease. These readers like to pick physician's brains or are interested in hearing something that validates their pre-concieved notion about their prognosis or other concerns. Of course, there are the occasional readers who are just interested in medicine as a field. But I digress.

Whenever one of these posts gets written, and this discussion begins, there is always one or two comments from readers who are truly convinced that their physician made a mistake, or missed something or just plain didn't know. This time the reader goes by the name "Bluedude". As they say "if you live in a glass house don't throw stones" so I will be happy to address him as "Bluedude".

Bludude writes:

"My father died very suddenly, and it was revealed that his doctor, also personal friend, missed the spot on his lung on the xray. We are not a litigious family and people do make mistakes. But what infuriates me is the way each doctor consistently stood up for each other, and my dad's friend kept reassuring my mom that there was no way he could've been diagnosed by the xray. Everytime he said that, it made me angrier and angrier. If doctors make a mistake, which they will, since they're only human, please don't lie to my face. Also, we asked the oncologist, and he just kept stating he didn't have a chance to review it. Be honest, be remorseful; show that you care about this patient, at this time. There would be less law suits if doctors didn't circle the wagons so readily."

This is not the first time I recieved this kind of response. I believe that Bluedude really is upset by what he believes are "physicians covering up for each other". I do understand how the situation can appear to be as such but please allow me to offer some counter-arguments you may have not given any consideration to. The reason I am going to do this here is because if I were the one being confronted by this family memberI would probably not point this out, in fear of being misunderstood, further worsening the situation and infuriating the complaint or because it would simply take wayyyyyy too much time and the person with whom I am having the discussion does not have the approprate background knowledge to begin to understand the full ramificaions of what I am saying. Especially when they are angry and more closed minded. I believe this phenomenon occurs because on television decisions seem much more straightforward. X-rays always tell the truth. CAT scans are perfect, an MRI, undeniable! If only things were that simple in REAL LIFE medicine. Please don't forget that television shows are aimed at the general public and have to be extremely simplified. A shame, since the general public gets most of their impressions about medicine from a very simplistic version.

Here is my response:

Dear Bluedude, My deepest condolences on the passing of your father. I do understand how you came to believe that your father's physician made a mistake and, inferring from your response, he ultimately was diagnosed with lung cancer (I am not sure of this, however, you do mention an Oncologist being involved).

First, please allow me to discuss a personal story:

My father, then 49, continued to complain about chest pain radiating to both arms for about two months. He continued to return to his PMD with the same complaints however all the EKG showed nothing. I was still a student in college and did not understand medicine and certainly not interested. His doctor repeated an EKG on each occasion which (according to him) did not show anything.

When my father, finally, was reffered to see a cardiologist he went straight to cardiac catheterization (after the Cardiologist saw his EKG) which showed severe obstructive disease of the arteries to his heart. He needed an immediate triple bypass surgery.

For a long time we were very angry at our PMD for what we believed was ineptitude at reading an EKG. We never sued him although we didn't return and changed PMDs soon afterwards.

Now, after having studied medicine I do understand that what he was looking for was a CHANGE in the EKG. Which is medically legitimate. Although, I certainly feel a stress test was in order earlier I do understand that what he was doing was appropriate, if for example, he did not think the pain was truly cradiac.

Now, let's discuss your father. You believe that his doctor "missed" a spot on your father's CXR. OK. But have you thought about this:

1. Are you sure that the spot was truly lung cancer? (in your case it may have been but I am just making a point)

2. Was that same spot there before and therefore there really was NO CHANGE on this Chest-X-Rays from previous ones, something that would go against this "spot" representing a cancer?

3. If this WAS cancer, was it what really caused his death? Cancer usually causes a slow deterioration, therefore, dying suddenly is more uncommon (not to say it doesn't happen). Could your father have died with lung cancer, instead of, from lung cancer?

4. Where was this "spot" on the x-ray. Could other things have explained it in the medical history of your father, maybe it was an Aspergilloma (I know you probably never heard of this diagnosis but it goes to further point out that people not trained in medicine lack the knowledge needed). Maybe things he didn't ever tell you but did tell his physician. This may have caused your father's physician to choose observing this "spot" for growth as opposed to subjecting your father to a dangerous biopsy that would have caused his lung to blow and then really cause him to die.

Just understand that medicine is not as straight forward as it looks on TV. Chest X rays are imperfect, so are CAT scans (they sometimes show results which only cause further unnecessary workups- One, put the patients at further risk for procedure complications and are expensive). So are MRI's for that matter. Medicine takes EXPERIENCE and association of SYMPTOMS WITH results.

You can always second guess your physician. That doesn't mean you have any clue about what was really going on OR what were his considerations at the time. He may have only been trying to protect your father from a painful and unnecessary workup. You've never seen a complication from a procedure cause a patient's death, I've seen many. So has your father's physician.

5. Finally, By the time a mass appears on a CXR (if it is lung cancer). The disease has usually allready metastisized and the cure rate is EXTREMELY low!!!Meaning, chances are that even if he did pick this up and did subject your father to a painful workup and chemotherapy it would not have changes the ultimate outcome.

Furthermore, most likely your father's physician never even saw the x-ray, the radiologist who read the Chest X-ray may have missed it. Your PMD usually only recieves a report of the reading.

I've tried having this type of conversation with others who have similar beliefs but it's really too emotional for the other side and their view is too narrow and set on blaming someone. Again, I am truly saddened for your loss. I don't know if anyone is to blame after all but I'd like for you to consider that maybe nobody is to blame and everyone lost someone they loved (including your father's physician and good friend) because everyone dies sometimes and life is unfortunate and cruel in that way.

Happy Thanksgiving Everyone

2005-11-23T09:53:00.000-05:00

I'm thankful my residency is over in 7 months. I'm thankful I'm no longer a second year or an intern. I'm thankful my residency is almost over. I'm thankful for a wonderful healthy girl and a loving wife. I'm thankful my residency is over in 7 months. I'm thankful for a beautiful world full of beautiful sights and gorgious women. I'm thankful my residency is over in 7 months. I'm thankful I'm a third year resident. I'm thankful that interns do my scut work. I'm thankful for not doing one guaiac exam myself this year, not one. I'm thankful my residency is over in 7 months.

I'm thankful my residency is over in 7 months.

Happy Thanksgiving everyone.

Sincerely,
Joe

I'm Getting Sued

2005-11-21T20:00:00.000-05:00

Or Shall I say "We are getting sued".

It's about a patient I've cared for as a resident who had a bad outcome. The lawsuit is by no means a surprise. I had a feeling it would head in this direction from the beginning.

I know you don't want to hear me bitch about this. Neither would I, so I won't do any of that. I would like, however, to document a few things that I can take away from this lawsuit that may, still, make me into a better physician or, at the very least, prevent me from being sued again.

For one, when things with the family appear strained, or tense, make a strong effort to document everything. Everything that they say and all of your responses. This does, however, become difficult because it will eat up a lot of your time.

Two, when the situation is heading in the wrong direction make a strong effort to document everything. Today, the impression is that an unfavorable outcome is automatically the physician's fault.

Three, get the family involved early. In fact, a good question to a patient when admitting them is if you can discuss the situation with the family. I suggest calling the family on admission so that they understand what is really happening. Try not to commit any HIPAA violations in the process.

Never say that things are looking "great" or "good" or "wonderful". You may use words like "Better", "Improving" or "Heading in the right direction" but make sure to mention that the overall situation is still bad. This will cushion the shock if something doesn't go as planned.

Never ask about a DNR the first time when speaking to a family even if the patient is crashing. They will become paranoid that you are not doing your max to cure their loved one. People really are distrustful of doctors these days. That is real! Wait at least 24 hours before asking about a DNR.

I have to face how this makes me feel. The truth is that I have no idea what exactly went wrong. I've had a chance to look through the chart and I am still unsure. But it doesn't mean I'm a failure or that I made a mistake. And even if I made a mistake I was hoping to take some lessons away from the experience. Unfortunately, I can think of other cases where I did make a mistake but the only thing I can really learn from this case is how to prevent myself from being sued. Which won't make me into a better physician by any stretch of the imagination.

I'm mostly nervous about having someone look at all of my decisions under a microscope. Can my judgement really withstand that sort of scrutiny? We all make decisions and many times those decisions are based on instinct.

Since that case I've been a better doctor. That's the simple truth. Much more careful about every single decision I make. Many of my decisions are based on my own welfare and not necessarily the patients. They are based on what someone may say in court. They are based on my need for future employment and malpractice insurance. I do, however, feel that ultimately the patients are better cared for and that is what counts.

Residency teaches more than just medicine.

It's My Blog, Whaddayagonnado?

2005-11-21T18:12:00.000-05:00

I've been thinking about money lately. I think the reason is simple: I love money! There I said it. Finally, it's such a relief, I'm out of the closet.

Naturally, I've been doing a lot of reading about the topic. Mainly, reading about buisness and investing through various blogs that deal with...'buisness and investing'. I happen to find some of these pretty helpful. Not in that 'How can I help a fellow human being' helpful but more in the way of 'How can I make myself rich' .

Some of the most interesting things I found were quite discouraging. For example, did you know that had I not attended medical school the odds that I will be rich would have been much greater. Do you know how much compound interest can add up to given an extra ten years head start.

The lifestyle that physicians need to maintain can also add up to a lot of cash. Those Armani suits aren't cheap you know.

Now, I know most of you will say that my future salary should more than make up for the lost time. Possibly. But, don't forget that I am starting in the minus. Medical school loans will haunt me probably for the duration of my physical being. Should I die, I'm convinced the collection agency will find a way to contact me. they will ask that I work out an alternative payback plan. Maybe I'll be the collector's guardian angel, for a fee.

Recently, I read Rich Dad Poor Dad, and you might say it certainly made me think. There are also tons of blogs out there that deal with money and many of them will be popping up on my sidebar soon enough. Not so much so you can go and check them out but more so for me. I do recommend the rest of you residents spend some time reading up as well. We can all use a little education about money and it would be quite refreshing to take care of yourself, once in a while.

I apologize that the medical comedy you come here for has been noticeably absent recently but I have other things on my mind. This is a blog about a journey through residency and finance is certainly part of that journey.

Enjoy:
Wealth Junkie: A young man's journey to becoming a billionaire.
Phil Town, Rule #1: Attempting to teach a special method of investing. That is Rule #1.
Fat Pitch Financials: Currently covering 30 days to becoming a better investor.
Frugal For Life: Currently hosting the Carnival of Personal Finance.

Of Course, I take no responsibility for any of the advice on any of these blogs. I do however encourage learning about investing. This is certainly one course I unfortunately never attended.

If any of you know other sites I should be reading please metion them. I'm always open to suggestions.

Things To Do For My "Inner Child"

2005-11-18T20:08:00.001-05:00

Recently, Misha (sorry no address) wrote a response to one of my posts:

"madman--you sound depressed. I think you need a diversion. How about a post of things you promise to do for your inner child.....Kind of a "to do" list. Not important achievement kinds of things....crazy things...fun things....things you have never done. You are clever....I trust you can come up with some good ones"

I thought "Heck, I spend half my day day-dreaming anyways so why not actually write down what I would love to do. So here it is, a list of what the 'little me' would really enjoy doing and then things I promise to actually do: (Some of these will get me in trouble)

Things I Would Love To Do:

1. Fly in a hot air balloon
2. Take a submarine trip
3. Scuba Dive in the Sainai
4. Try Cocaine
5. Learn to Tango really well
6. Perform in a play
7. Take a home renovation course
8. Make love to Adriana Lima
9. Meet Some of My Readers in Person
10. Fly a plane

Things I Promise to Actually Do:

1. Take a submarine trip
2. Scuba in Sainai
3. Perform in a play
4. Meet some of my readers
5. Learn to tango
6. Make love to Adriana (If she lets me)

I guess that's a big "If"
Have a great weekend

The COTV

2005-11-16T10:24:00.000-05:00

Over at Charles. And...He placed me first, I love you Aiden!

Possibly the Most Hysterical Thing I've Ever Read In a Medical Journal

2005-11-15T17:10:00.000-05:00

I feel so badly pouncing on this when really it's so much more ideal for the blogs of my emergency physician friends. the Annals of emergency Medicine October 2005 issue published an Article titled "The Next Generation of Emergency Medicine Reality Television". It's possibly the funniest thing I've ever seen in a Bona Fide medical Journal (if you consider EM medicine???). Props to Jeffrey Freeman who wrote the piece. Truly Mad my friend, I love it. Please excuse me for publishing it here. I have no money, really, I promise, none. Forgive the EM joke, that's mine, figures right?

As any emergency physician knows, it is normal to ride through the hallways of the hospital doing CPR atop the chest of a dying patient while shouting out orders to nurses at the top of their lungs—at least on television. And, while miracles occur in emergency departments (EDs) every day (such as a specialist coming in to see a patient), they are not always sufficiently dramatic for prime time. Like it or not, the American public learns more about emergency medicine from the television than from their personal experiences. ER has just finished 10 seasons; Trauma: Life in the ER has finished 7. Since it's only a matter of time before these shows fade from the airways, a replacement will soon be necessary. In this era of reality television, something that will grab the public attention and let them feel the true grit of today's ED is needed.

The following are reality television proposals for the next generation of emergency medicine viewers:

The Resident—A powerful and omniscient residency director starts with 12 emergency residents and each week fires one resident and gets all the remaining residents to work the extra shifts vacated. The last resident working gets hired to a large contract management group, but not as a partner.

Joe Emergentologist—Ten patients compete for the attention of Dr. Joe, the only physician working in a small rural ED. Each hour, Joe transfers off 1 patient to an alternate facility. Imagine the patient's surprise when it's finally revealed that Dr. Joe is only a moonlighting first-year dermatology resident, with no experience in any ED. Will the last patient standing still accept the loving care that Dr. Joe offers when they find out the truth?

Waiting Room Survivor—Twelve patients are stranded in an isolated, barren waiting room, and triage is closed. Who will survive? Without water or food, they have only their wits and the will to survive. Each week a patient is voted out of the waiting room. As they form tribes and win challenges, they struggle for the ultimate goal: any available treatment room.

ER Jeopardy—In this game show variant, 3 emergency physician contestants try to guess a patient's diagnosis, but the answer to every question is another question. Categories of answers include such puzzlers as: “What Language Is That?,” “Nominal Aphasia,” “Geriatric Confusion,” “In2bated,” and “Toxic Delirium.” Losers get sued, and the winner gets no actual cash or prize, but does get to come back for another shift and the satisfaction of a job well done.

The Mole—A high-volume ED, and one of the staff is sabotaging patient care. The Mole changes lab results, erases orders, and gives wrong doses; each week another abbreviation is cut from the list of accepted abbreviations. Can the emergency physician find the Mole before another patient calls their attorney? Sponsored by the Institute of Medicine.

Patient Extreme Makeover—A team of top-notch support services: social worker, physical therapy, occupational therapy, and dental hygienist, take a frequent ED visitor each week and work their wonders. Consultants are called in for bariatric surgery and laser tattoo removal; clothing is donated from the local thrift store. The patients return after their complete makeover with a new chief complaint, and the ED staff can't recognize them until they ask for Dilaudid…

The New Price Is Right—Forty-five million uninsured audience members are invited to the television studio ED waiting room, where 4 contestants are chosen to possibly win some medical care. To win, they've got to guess the price of industry-sponsored drugs and medical procedures. Those who guess closest are invited to a final showcase, where they try and guess the complete cost of their medical treatment before succumbing to their disorder. “Come on down!”

The Simple, Poor Life—Two consultant physicians, both from fabulously wealthy subspecialties, are sent to live and work in an ED for a month. Each week they are given a different job, from unit clerk through transport and housekeeping. Can they get through one last shift without getting their clothes dirty? A laugh a minute…

Who Wants To Be a Millionaire?—Two physician CEOs compete for an ED contract, trying to underbid and underpay their employee emergency physicians without going over the contract price. Three lifelines are given: “Noncompete clause,” “Restricted access to billing information,” and “Call a Friend.” Winner gets a million dollars and retires early from medicine.

American Idle—Each week, 12 patients wait hours for lab and radiograph reports while their medical conditions deteriorate and inpatient beds are unavailable. Radiologists and audience members can text message their vote for favorite patient to be admitted.

And finally, Fear Factor—This could be the ultimate ED program. It's apparent that the potential for an endless series of reality-based episodes of pain, terror, and inedible food is available. Just like a career working shifts in any ED.

Note 1: If anyone wants to consider hiring an emergency physician as television producer, please contact the author immediately.

Note 2: JCAHO has reviewed this article and would like to remind emergency physicians who shout out orders while performing CPR while riding stretchers down hallways, that for verbal orders, please verify the order by having the person receiving the order “read-back” the complete order. Thank you.

Some Completely Useless Random Thoughts

2005-11-10T19:27:00.000-05:00

Well, like I stated in the previous post, if you have nothing original to write about then you should just avoid posting. I think that not posting is a legitimate choice. No one expects that you post every day. Although I know some people who can, Maria, I am by no means aiming to do just that. So I post when I have something to say or when I want to link something I find interesting.

Today, I have nothing medically related to write about. I haven't written a post on future intern either, although that's not too far away, she's too cute for me to share right now. So What I decided to post about, which I realized I never do, is actually what's going through my mind. As boring as this can be these actually are things that I think about and can give you a good uderstanding of my ADHD affliction. They are not medically related.

These thoughts are totally random. Read on if it interests you otherwise come back some other day, maybe I'll think of something worthwhile.

I like to go through the 'blog's of note' that blogger picks every month. Sometimes I find blogs with truly exceptional writing or concerning subjects that I know nothing about but would interest me. For example, out of this month's batch I think that this blog about animation is quite interesting. Although I am a big fan of Pixar and Disney, animation is not a subject I could discuss intelligently. I'm happy blogger found it and maybe I'll give it a read once in a while.

This other blog about Taxes also really interests me. I am making a really big effort to investing in understanding finances and taxes are a huge part of this education. I read in a book that said we spend from January to May working just to pay off our taxes. Five months just to pay taxes. I don't know about you, but that scares me. I never really thought about it that way. I'm also trying to establish a few buisnesses on the side right now. I think today's physician has to know about investing if he/she intends on living comfortably. I really hope to avoid the excessive work that most internists find themselves trapped in. The only way I'd succeed is if there is money coming in from other places. Maybe my background in buisness can help me here.

Another blog called about camera tossing looks really cool. I really don't have much to say about it other than that.

The rest of the 'blogs of note' are more personal and people post about their life etc. Although I do much of that here I usually don't find that it interests me too much. If anything, this blog deserves an honorable mention for the coolest logo.

Which brings me to my next point: Please change your blog wallpaper from the standard ones that Blogger offers. I know some of you are afraid to mess around with the Template but this is really not very difficult. You can do what I did and just start another fake blog with your same current template and mess around with that one. When you figure it out then do exactly the same changes to your blog. I know you shouldn't judge a book by it's cover but I think it just makes your page look a little bit more cool.
Tip: A good way to start is to find a wallpaper you like and look at the "source" code. You can find that by scrolling down from "view" at the top menu on Explorer. I learned a lot from doing this.

I'm afraid my life will go by and I won't notice. It's already happening.

I miss being single. I'm thrilled that I'm married.

I'm really tired of using Mad House Madman as a name but I'm afraid most of you will completely butcher my real last name, it's spelled incorrectly. This is the curse of my life. It's gotten so bad I've stopped correcting people. Really, everyone at the hospital has been mispronouncing my name for three years now. I never bother to correct them. I'm tired. My real first name is Joe, short for Joseph.

I'm from Israel where there were terrorist bombings every day. Innocent people died. This went on for decades and the world didn't care. Not until September 11th. So now when there are attacks in Moslim countries, and Moslims die, deep down I don't know if I feel badly for them. I feel guilty about that but it's the truth.

I find it outrageous that this country is not outraged by the war in Iraq and by the administration that sent our kids into a warzone on false pretenses. They are dying there and I can't understand how the idea that there will be democracy in Iraq is worth their lives. I don't really believe that the democracy will survive ten years after we pull out. What are we doing? What did we do? You say that they didn't know that there were no WMDs? since when do we accept ignorance as an excuse? Especially when it lead to so much damage. I voted Republican in the first election and Democrat in the second.

I don't know how long I can keep being a physician. I give myself ten years and after that, if past performance is any indication, I will move on to something else.

I wish blogging was worth something. I guess it is because I'm interested in how people respond to what I write and what they have to say. But it's not worth anything financial, only personal.

I wish they featured my blog on 'blogs of note' when I started, it would have made getting a readership much easier.

This post wasn't edited at all, so excuse the poor writing. Shortly, I'll get back to writing medical related posts. But words on a [age can never describe the person writing them.

Have a great weekend, you deserve it.

Not the Way to Blog

2005-11-10T18:53:00.000-05:00

This Jackass ripped my post off and didn't even link back. I'd report him to MSN but they can't do anything. Give me a break.

So, as you can see, this "some guy's blog" is calling you out Jackass. And I wrote him a great comment to boot. I guess that's as good as it's going to get for this violation.

Really people, if you have nothing original to post, either don't post or make sure you give the credit to the person who wrote it.

Thanks to a friend for informing me.

SoundPractice interviews Chris Rangel. Another Interesting Interview

2005-11-09T18:00:00.000-05:00

I recently discussed the podcast interview with Grunt Doc and now Chris Rangel takes center stage at SoundPractice. I don't know why I like to blog this stuff but I find it interesting to actually hear what people think and how they interview. I particularly like blogging surprises.

So you ask, are there any surprises? Yes.

First, Dr. Rangel was asked if he'd do this again and he did the same song and dance that Grunt Doc did except, in the end, he said "No". It took a while but it finally came out. So I'll save all of you the long pause, Would I do it all over again? The correct answer is actually "Hell No!". I agree Dr. Rangel.

One great question: Do you think the public is sympathetic to the pressures of medicine? He says no but I'm not sure. So are you?

And...Rangel used to be a hospitalist. Maybe he can throw a few tips my way. I'm really torn between going to outpatient versus staying in the inpatient setting.

What's the best blog he ever read? Well...I can't give the secret away, you need a reason to listen to the interview.

I'm thinking more and more about interviewing as well. I'm getting some requests from other sources to interview but I keep wondering what they're expecting to hear? I'm not a very pensive human being. Would any of you like to hear my voice?

Grand Rounds and Congratulations Maria

2005-11-08T06:43:00.000-05:00

Grand Rounds 2.07 is up and Rita from Msspnexus does a great job of weaving the whole thing into one great story. I wonder where she got that idea from?

While you're surfing why don't you go on over to Intueri and congratulate Maria on her blogs' five year anniversary. Wow...that's sticking to a hobby. She's a great writer so have a look around. There's more than enough reading for you to do today.

Oops, I Found a Vacation

2005-11-07T14:32:00.000-05:00

I guess you could say I’m playing hooky. My program is under the impression that I’m at a private prestigious cancer center doing an Oncology elective. The prestigious chiefs of Internal Medicine at the prestigious Oncology center are under the impression that I’m doing my elective at my home institution. No one bothered to check and so I ‘sorta’ forgot to let any of them know. Oops.

Which leads me to my next thought, what do I do now? If I wasn’t looking for a job this would easily become time for a little R&R, maybe a nice ride to Montreal to meet up with some friends and visit strip joints. But I’m looking for a job and that obligates me to looking over my resume and writing a cover sheet. And I’m having a hard time coming up with a cover letter that indicates that I'm the perfect man for the job.

My indecisiveness is nothing I like to flaunt. I don’t even know what I really want. I think I want to be a hospitalist. The thought of taking care of really sick people for the rest of my life doesn’t appeal too much, but then again, the thought of teaching students does. And then what would I teach them? If I only took the time to read some medical journals, well, that would help.

I believe my whole life I’ve been cursed with a plague of insecurity. Once again this transition, I fear, will bring out the worst in me. Residency is over and I’m clueless and extremely apprehensive about what comes next. Raving about what extremely great qualities I offer on a cover letter feels like a big joke.

I know bums with less of an inferiority complex.

Selective Hypocrite Memory

2005-11-03T17:56:00.000-05:00

The Mad House Madman drives down the lane with three seconds to go. He pulls up short. Look at how high he can get up in the air. Oh my god, is that a plane? Is that a helicopter? Why no, it’s the MHMM….The shot for the game is….GOOD!!!!! (The crowd roars)…

That’s the way I preferred to remember it. So when my best friend asked me to fill in for a missing teammate on Monday night I figured I still had that touch. It’s only been, what, twelve years since high school? I mean, I was on the Varsity team you know.

I learned a lot that night. Memories are better left unvisited because the truth can sometimes be ugly, not to mention embarrassing. Not only had I discovered that my stamina rivals that of a nursing home gomer, but I also discovered that I can’t shoot, and I don’t mean I can’t hit the shot, I mean I can’t SHOOT. I had actually forgotten the technique for shooting a basketball. I forgot the TECHNIQUE. Do you know what this means? In short, AIRBALL!!! Can you hear it? “AIRBALL…AIRBALL…AIRBALL…AIRBALL”. All in all, four of them “AIRBALLS”.

But it was deeper than that. It was the realization that no matter how late I stayed to stabilize a dying patient, or to comfort a grieving widow, there was one thing I surely wasn’t doing much of recently, exercising. Wasn’t exercising. Five minutes into the game I was huffing and puffing so hard you’d have thought I was trying to blow the house down.

What a hypocrite! Here I am telling these poor sixty and seventy year olds with multiple horrible disease processes that they need to exercise more and I can’t even last ten minutes. Me, barely 31. Shameful hypocrite!

Reality has set in. Three years of residency have taken their toll on my bronze greek god of a body and my youthful gorgeous exterior (Memory is selective). I can save the life of a man having a heart attack but I can’t hit a shot to save my own.

Somewhere, Micheal Jordan is quietly weeping.

The Tangled Bank By Charles?

2005-11-02T12:27:00.000-05:00

Charles is hosting the Tangled Bank. I, of course, had no idea.

Spooky Grand Monday

2005-10-31T17:40:00.000-05:00

And I thought Grand Rounds were a Tuesday thing. Oh well, it's Halloween, strange things happen.

Those Difficult End of Life Decisions: trick or TREAT. Happy Halloween Everyone

2005-10-31T16:50:00.000-05:00

How Many Have You Killed?

2005-10-30T05:51:00.000-05:00

Yesterday my most stable patient arrested. She was admitted as a purely social admission one week back, she was found without food or a place to stay and was brought to be placed in a homeless shelter. It was around lunchtime that her heart stopped beating and I was told that she was found with food in her mouth, turning blue and unable to breath. Shortly afterwards her heart arrested and we were able to bring her back fifteen minutes later. The chance of meaningful recovery is miniscule and I’m afraid that she would have probably been better off dead. My only conclusion is that she most likely aspirated her food.

I have to admit that the news really shook me. Whenever a patient dies I question myself as a physician. What was missed? Was I to blame? Was there something I did to provoke this? Could I have prevented this? Was there something I should have been doing differently? Were there any clues?

Sadly, the clues are often hidden. Which makes hindsight so cruel because it makes so much sense. But interpreting a human being is so difficult in real time. Looking back, my patient lost a lot of weight; she vomited once or twice during the week she was there. Last week she hinted that sometimes she has trouble swallowing and I was monitoring her to see if it was true. After a few days of trouble free intake I concluded that her ability to swallow was intact.

I’d like to say it’s the first time I failed to put two and two together but that would be a lie. Unfortunately, experience in medicine is paid in the blood of others. How many will pay before my mind and senses work as one god only knows. Until then, the clues will hide in scripted notes written by interns and residents and consult notes. One day the hints will jump off the page and present themselves as clearly as the moon in the night sky. Until then, I will be the evelasting student.

How many have you killed?

Hindsight is so cruel to the physician.

Conversation

2005-10-26T06:27:00.000-04:00

Random conversation with an acquaintance

"Oh man, my back is killing me, I should sue that bastard"
"how long have you had it?"
"Ever since the accident"
"What accident, are you talking about that one you had when you were twenty?"
"Yeah, the Orthopedic repaired my pelvis after it was shattered, my whole acetabulum. After that they laid me out in bed with pulley's connected everywhere. My right leg is slightly longer than my left due to that idiot and now I have this chronic back pain"
"So now you want to sue him?"
"yes"
"Because you have pain in your back"
"yes, if he didn't tell me to lay in bed I wouldn't have this pain"
"Yeah, but didn't he save your life?"
"What do you mean?"
"If he wasn't there to put your pelvis back together after you fell asleep behind the wheel you would have been crippled for the rest of your life. At least you're walking now"
"Yeah but I have this pain sometimes"

Why do some people fixate on the most insignificant details while missing the big picture? We've been spoiled. Rotten now.

It's Been a Long Time. Grand Rounds

2005-10-25T12:39:00.000-04:00

The Grand Rounds are up at Hospital Impac t and it's been a long long time since I've plugged it. Shame, it's where I first got started and got noticed as a wildly entertaining and informative blog. Right?

Looking through some of the posts I'm amazed how I've managed to not notice all these new medical bloggers out there. There's some great med-blogging going on and some fantastic new writers. I guess it's time to update my link list.

Other Updates: the Amazon ad has been removed from this blog just in time to hide it's author's desperation for medical school loans repaymeny funds. Well, don't worry about it. This blog is free and I don't ask a penny of you to read it. Not one penny. Even though I waste my precious time solely to entertain my readers. Time when I could be making money to feed my ten starving children and my anorexic, not by choice, dog. But really, don't worry about it, you just go ahead and enjoy this blog. BTW, thanks for buying from my amazon portal. The 92 cents I made are now invested in a retirement fund. I hope to net 32 cents by the time I'm 65.

My links were updated last week. I managed to remove some of the now inactive blogs and to add one new one. This, no longer anonymous med-blogger (since he's been on the 'blogs of note' this month) Ah yes Medical School. It's pretty entertaining and he's chosen the blue template. The same one I chose to begin with before I updated to this new and much more hip template- That I really need to change.

Grunt if You Like It

2005-10-22T13:16:00.000-04:00

GruntDoc recently gave an interview to Kent Bottles that he posted on his site. In spite of his own assessment I found the interview interesting. I also thought that it was entertaining to hear what he actually sounds like.

Some very funny moments when he was asked if he would do this again. I think the awekward pause he managed to mask with the old "aaaaaaa....." (must've been thirty seconds) was hilarious. I can only imagine what was going through his mind but I know the feeling: "I would, heck no I wouldn't, yes I would, no way, yes, no, yes, no, heck I don't know, what the hell else would I do anyways..."

When asked about his favorite blogs he must've simply forgot to mention this one. I'm sure it was on the tip of his tongue but the tension of being interviewed made him forget the name "CHRONICLES OF A MEDICAL MAD HOUSE!!!!" Right???

I was also asked to be interviewed but so far I haven't come to a decision if to participate. I can't imagine I'd have anything interesting to say. Frankly, I think some of my answers really depend on which side of the bed I wake up that particular morning. Some of the things that would come out of my mouth may just really frighten my readers. Of course no one wants to hear that.

Supersize It

2005-10-19T21:21:00.000-04:00

You remember that joke from the House of God about the patient who had a blood pressure of “Patent Pending/150”? For those who never read the book (You better read it): The words “Patent Pending were written at the top of the mercury column used to measure the blood pressure. Since the column would go no higher than this then the man’s blood pressure was “Patent Pending/150”.

So when I walked in one morning and checked my census it was no surprise that there was an extra patient or two, there usually are as the admissions that came in over night get assigned. Looking over some of the information available on the system I noticed something peculiar, and frightening. The official weight of my new admission was “>800 pounds”.

I know, you curious as to why use the “>” sign as opposed to an actual exact weight. In short, our beds can only record weights up to 800 pounds, anything over gets recorded as “Who knows, god help you” or “>”.

At first I was sure it was a mistake. Must’ve been someone who was trying to enter 80 and simply, mistakenly, pressed the zero an extra time. Could this be real? Can any human being really be bigger than 800 pounds?

When I arrived in the vicinity of the room I could already smell the stench. There was a smell that was slowly charging upon the ward and it was terrible. At that moment I had a bad feeling that this was probably the real thing. And it was.

Laying in bed, in moderate respiratory distress, was the biggest person I’ve ever laid my eyes on. His bed took up the entire room, it was the width of one and a half hospital beds and it was barely holding his massive thighs from unhinging the railings. Mr. Micheal K. had a very bad case of asthma. He was wheezing heavily. I could hear him from across the room.

I introduced myself to the giant who quickly turned out to be a gentleman of large proportions and I told him the treatment he would receive and that I hope that he’ll respond quickly and that we could return him to his home as soon as possible. I proceeded to do a physical and had to change sides of the bed to finish my abdominal exam. Palpating anything in his abdomen was impossible. My note said something like “Wheezing bilaterally, cannot effectively examine rest of patient”. I hoped to get him out fast.

Boy, little did I know.

Later on that day Micheal had a massive upper GI bleed. Finding veins for a large bore IV was impossible. Central lines were too difficult but luckily some poor surgical intern was finally able to do it, somehow. We began repleating blood. “Page GI! STAT”.

Micheal was getting worse by the minute. He had multiple large black bowel movements and was vomiting blood by the buckets. Getting a blood pressure was also impossible. Even our largest cuff didn’t come close to being appropriate. Any CT scans were out of the question since Micheal would probably break the machine and certainly would have severe difficulty fitting in the CT machine.

Due to his severe asthma, doing an Endoscopy was very dangerous and the Gastroenterologists would only agree to do it if he as intubated and only if it was done in the operating room. Somehow we pushed the bed through the halls and up to the operating suite. ENT came to do a nasotracheal intubation which was nearly impossible. It took the chief ENT resident nearly five minutes to find his trachea. Micheal couldn’t be anesthetized due to his pulmonary status and was writhing in pain from the intervention. Finally, he was intubated, awake, and bleeding.

The Gastroenterolgists went in. It took a little time but eventually we found the bleeding Duodenal ulcer that was causing the mayhem. It was cauterized and the bleeding stopped. Micheal was extubated and in severe respiratory distress.

He somehow came out of it after some asthma treatments. The rest of the hospitalization was unremarkable. He left three days later. I don’t know where he is or if he is. Hope his situation had improved but I’m a pessimist.

The WSJ Loves Me???

2005-10-16T08:55:00.000-04:00

Recently, the Wall Street Journal published an article regarding medical blogging (Republished here). I was surprised to see this blog mentioned. It’s described as “An anonymous medical resident blogs about the often chaotic world of doctors-in-training”. Which got me into thinking, is this really about the chaotic world of doctors in training?

I think it’s more about my perception of this world. It’s about both my personal and professional experiences and the thoughts that they provoke. Everyone’s experience differs and my experience is, by no means, universal.

I began this blog because I love to write. In the beginning, I wrote more personal things. Eventually, I stopped writing this way for various reasons. I began to discuss some relevant medical issues, but let’s face it, this blog is medical in the same way that porn stars are actors, meaning, if you think it is than you’re really not paying attention.

I never wanted to be a physician. In high school I was a brat. So, I was accepted to a city college. I dropped out twice. The first time it was because my father got sick and I needed to help at home and the other because I found nothing that interested me. I rarely studied in college which earned my rightfully deserved Bs and Cs. Actually, I always saw myself as a businessman rather than anything in the medical field. Probably, I would have made a much better malpractice lawyer than a malpracticing physician.

Later, after getting fired from my third salesman position I decided that I would be better off a professional. After returning to college and discovering medicine I took all the pre-med classes in two semesters and applied to medical school. So it was no surprise I was only accepted in Israel, in spite of doing extremely well on the MCAT. In the end, those slacker years (and the GPA they destroyed) returned to bite. So why am I telling this story?

According to the article I am the representation of the common thoughts of “doctors in training”. I really doubt my fellow residents have the same thoughts as I. Many of them grew up wanting only to be doctors. They are more serious, more committed and more devoted to medicine than I can ever be. I constantly question why I entered this field and if it’s the right one for me and it reflects in my writing. At times I write about how happy I was to save a patient or how sad I was to lose one. Sometimes, I hate this field. I can also write about how to kick patients out or how disgusted I am with malpractice litigation and the patients who decide to sue. I run the gambit on dispositions and moods and it often reflects what my experience is at a certain point and time.

Not for one minute do I think that this is a universal experience and neither should you. I make no apologies for what I write simply because I don’t write it for others, I write it for me. It’s my therapy and if it upsets you than don’t read it, it’s there to save me the money I would spend on psychotherapy. God knows I need it.

Don’t misunderstand, I am honored to have been mentioned in the article along with some of the really fine medical bloggers out there. I’m very happy some of you take the time to read through my posts. But please don’t take this to be the thoughts of every doctor in training you meet. It’s really the random, crazy, obnoxious, passionate and personal feelings of a business career gone haywire.

First Rule of Residency, Eat When You Can

2005-10-16T08:51:00.000-04:00

Friday: the Worst thing I ever asked my Intern to do. Poor Intern

2005-10-14T16:50:00.000-04:00

Back on the wards and, as my readers know, this means the "Friday 10 Random things I asked my Interns to do today". However, today I asked my intern to do something so infintismally (is that a word?) gruesome that I automatically deferred the other nine for next week.

As we were rounding on our 450 pound man with horrible CHF who can't even get out of his oversized bed he decided to give us the most colossal of complaints (for him). He said "Doc, I'm having the worst pain in my ass that I've ever had". I mean, those words (and their implication) produced substernal chest pain in me to the point of admission. Luckily, I already served my punishment in my first year of residency with my 800 pounder (let me know if you want the full story). So the joy of this complex rectal was all my intern's to do. Do you remember that joke, the one that goes "How many Interns does it take to perform a rectal exam on a bedbound 450 pound man?"

Four! and it is quite a scene.

You Guys are Even Meaner, I Love It

2005-10-14T05:11:00.000-04:00

In Response to the prior post, with which I expected half a dozen readers to write about how disguisted they are, some of the readers actually surprised me. How you ask? Well, it seems that some of you have a mean streak I could only dream of For example, Barbados Butterfly who really would let this patient have it:

- order a 24h urine collection & QID blood sugar levels with your diabetic work-up.
- find an embarrassing illness & discuss it loudly on ward rounds (tinea, bleeding haemorrhoids, some rash that isn't scabies but by golly it could be, we really should start scabies treatment & put him in the room with that other guy with scabies. Caution: do not do this if it will mean that the patient needs a single room).
- that rash won't get better if you shower with hot water. It should be somewhere between cold & tepid.
- no smoking & no alcohol. Cigarettes are tools of the devil. Make your patient understand this. And you need to put him on an alcohol withdrawal scale chart. Particularly overnight.
- strictly enforce a sitting out of bed policy between 0700 and 2200. You don't wanna get DVT, do ya?
- get physio to crack the whip. There'll be no slackers on this ward! NB. Check first that your ward physiotherapist is not a petite, svelt, attractive blonde.
- send every medical student in the hospital to do a long case on the patient. Send the short, slow medical student with the weird laugh. Tell him that you want a full dermatological, childhood and sexual history. Ask him to get some skin scrapings from that rash. Possibly even a punch biopsy.
- order chlorvescent rather than slow K for potassium replacement. I've only met two patients who liked the taste of chlorvescent; both were demented.
- vitamin D levels are often low. Caltrate tablets are big.
- Hip protectors are really cool, dude/dudette. And they're for your own safety. Put 'em on.
- Strict bowel control. A bowel chart with faecal descriptions. There could be colorectal cancer. We want regular bowel actions & we're gonna give you all the bowel meds you require to get you there. (this does not work if your patient ENJOYS discussing his bowels).
- early morning urine collections (three) for TB. What time is early morning? You decide.
- Nasogastric tubes.
- Abdominal ultrasounds. They're indicated for many reasons, require patients to be nil by mouth & often the non-urgent ones get delayed, & delayed, & delayed. Especially if there's some confusion as to who is ordering the test.
- Nightly reviews by the night intern. "Sorry to wake you, just wanting to check how the bowels/rash are going... and did you see that storm in Texas?"
- If there's a higher than usual risk of DVT you might need to order q8h subcutaneous heparin rather than just the standard q12h. Certainly don't give daily enoxaparin.
- If the IV is just a little dodgy you can avoid causing the physical pain of the IV insertion while inflicting the pain that is an iMED beeping ALL NIGHT LONG.
- Barium or gastrograffin swallows and enemas.We know the Shem Rules and how to do as much nothing as possible. But some patients need you to go all out if you are to get them back in the community where they belong.

And the best of all from Kel since I would have never thought of it:
The patient was discharged home and refused so the bed was discontinued from his room.

Oh boy, that's evil. I'm so proud.

The Resident’s Guide to AMA

2005-10-10T18:38:00.000-04:00

There were also patients that were grateful. It’s certainly hard waking at five in the morning to get to work but the satisfaction of knowing you helped a soul in need is more than enough to provide the necessary burst of energy. I slaved away most days collecting samples for various tests and running between families. Such was my intern year.

Yet once in a while, I won’t lie, there was that one patient, just one patient, I hated. Maybe “hated” is too strong a word. I didn’t hate him but I certainly wished something bad would happen to him. Deep in my soul, and believe me that I felt guilty, I wanted him to hurt. He was verbally abusive, he would put me down, he wouldn’t follow any of my recommendations and he would waste my precious time. He didn’t need to be in the hospital but he knew we couldn’t discharge him and this would turn into a very expensive hotel bed, with his own private doc.

There are patients you’ll hate for various reasons. Maybe they're ungrateful, verbally abusive, unlikable, strange or just plain unnecessary work. For me, they were usually the ones that didn’t need to be in the hospital but refused to leave. Yes, there are patients who refuse to leave. They are usually homeless and therefore, legally, they cannot be discharged or they are foreigners with no visas who need chronic care. So they stay.

Don’t misunderstand me, most of them are kind people and I have no bad intentions towards them, they understand the unfortunate circumstance and try to stay out of your way, creating very little problems. Rarely though, there is that one patient who’s mere presence incites nausea.

The only way to rid yourself of these patients whom you cannot discharge and don't want to leave is the AMA (Against Medical Advice) form. As soon as they sign this form they are free to roam the earth, free as birds, away from your wonderful efforts and your daily notes. Half way through my intern year I realized that, although I am only an intern, I have no obligation to absorb disrespect, or better yet, abuse. In fact, I realized something else slightly more sinister, although occasionally this borders on the unethical.

There are methods, when employed effectively, that can ameliorate some of this unnecessary workload. You will now discover the Madman’s Resident's Guide to obtaining the AMA. Follow these steps and your patient will leave, I promise.

1. Diet modification: The way to a man’s heart is through his stomach. So what if your charming patient’s diet order needed renewal and you happen to suddenly suspect he’s become a diabetic who’s developed chronic kidney disease. I know no one who would blame you for being prudent and ordering a “Low sodium and potassium, No concentrated sweets” diet, at least until the hemoglobin A1c comes back…”What? You say the test takes five days to return? Well, better safe than sorry”. In that case you may even be justified leaving him NPO for the next meal until you sort out if he needs immediate access. "What you say, his kidneys are working just fine?"

Phlebotomy: Of course your patient is refusing blood draws, you know that. But, you also know that having a phlebotomist wake you at three AM is simply irritating and if done religiously can damn near drive someone insane. So if you happen to continually order three AM labs you can’t be blamed, you were simply optimistic that this time he would consent. What he didn’t? Damn it, maybe tomorrow.

Intern Rounds: Instinct will sway you to see this patient last. But don’t do this, see him first and as early as possible. When arriving in his room be very dramatic, open all lights, swing open all the curtains, make a lot of noise. Ask very specific questions, stuff he’ll really need to think to answer. Forget the “how are you doing today?” instead try “Did you see the storm in Texas yesterday? How much snow did they get again?” This makes it really difficult to return to sleep (especially after you’ve turned on the lights and pulled open the curtains and asked him to sit up and walk for you so you can observe). The harder it is to sleep, the quicker he’ll get agitated. Do this often, several times every day, unnecessarily. Don’t be apologetic!

Nursing and Bed Board: (**Should only be used when all other measures have failed)Fortunately, there are two patients in every room. Presumably, you have no control over who the other patient is. But, knowing the right people can sometimes pay off, big time. I mean, dementia and incontinence and uncontrolled flatulence big time. I mean, vomiting and delirium in a loud old lady big time. I also mean ventilator and multiple alarms in the middle of the night. What do you mean he wants to move rooms? Sorry, doesn’t work that way here.

Have an AMA form ready in the chart. Instruct the signout person not to put up a big fight. The patient will be in another ER and someone else’s problem very soon.

Again, you didn’t hear this from me.

Is This Private

2005-10-05T15:46:00.000-04:00

This new month offers a different experience for a third year pro such as I. Off the city beat, I'm currently in a private, posh hospital full of private attendings and private patients. This experience is leaving me somewhat disappointed with the current state of affairs.

When people ask what I do I usually say Internal Medicine. "So you're a general doctor?" they ask and being so tired of trying to explain it I say "well, sorta". "So you take care of colds and give referrels for specialists and stuff like that?" that's the usual follow up comment. I often feel like smacking these folks but knowing quite well this may get me in trouble I just waive it off and say something like "I usually don't need a consult, I can take care of most things on my own".

And I can. I do. In my city hospital I am the internist, cardiologist, pulmonologist, gastroenterologist and everything else the patient needs. I only defer to these specialists when it's a problem I can't handle and that's not very often. I mean, I can read UptoDate just as good as the fellow can.

But here, in this private palace, I've being instructed to call consults for nearly everything. Patient has a cold call I.D. complaining of belly pain call GI. etc. etc.

I'm being reduced to a note reader. No, let me correct that, I'm being reduced to note reader number 4. After my intern, my sub-I, and my attending get a look at the consult notes I get to read them too. How amazing, I can read!

Is this really how pathetic Private Medicine has become?

Blog Spam

2005-10-05T14:28:00.000-04:00

All that keeps popping up on my email are all these comments from blog spammers. You'd think that this page was ranked a PR 9.

Frankly, I don't know what the page rank is but I would bet it's no bigger than a 2. So really, how much value is there to spamming here? Try the bigger guys like some of these Attending on medlogs or something. You can check back here next year. I really don't think that you're doing such a good job of search engine optimization and maybe that's the biggest insult, I'm worthless to you so go somewhere else.

If you must spam, and I'm sure you will so I'll stop trying to prevent you, please contribute with a worthwhile comment first and THEN tell me how good the viagra on your site is.

Really, who told you I need Viagra anyways????I mean...maybe but...no, that's never really happened to me...no, Really...OK, it happened one time but I was drunk...ok, not DRUNK but intoxicated.

Don't Say I Didn't Help

2005-09-22T12:27:00.000-04:00

As thousands of fourth year medical students struggle with their personal statements for the upcoming match I thought I would take this time to suggest some phrases that may catch the eye of your favorite program's director and raise your chance of success.

Attempt to build these phrases into your personal statement depending on your choice of future profession (I take no responsibility for the fool who actually takes me seriously):

Medicine: "I really love treating chronic disease. I particularly enjoy Diabetes. It always fascinated me how blood glucose can go up and then down and then up, and then down. I find it particularly interesting how certain medications will help and then stop helping, and then I add another medication, and then that will help, and eventually it will stop helping. Sweet! (I mean that ironically)"

Surgery: "As a child I always wanted to cut things open. Especially animals and dead meat my parents brought home from the butcher. I remember those trips to the butcher shop. The smell of flesh and rotting blood reminded me of daisys blooming in springtime."

Radiology: "I equate x-rays with human nature in that they look through our exteriors and into the heart of the being. As a child, I always wanted to have x-ray vision. Especially during my puberty stage."

ER: "OK, let me say it like it is. Yes, I'd like to forget everything I learned in medical school. I don't like patients and this is a great way to make tons of money and have absolutely no responsibility what-so-ever. And the shifts...wow...don't get me started on the shifts" (scathing review for this one will appear in the comments section and at Gruntdoc and at Symtym, I imagine)

Dermatology: "Skin, oh skin...how warm..and...protective...and...colorful...and it changes colors, say when people suntan. Which they shouldn't do...I love skin, did I say that already"

Neurology: "I was born to test reflexes. As an infant my parents can recall how I quickly took to the hammer. Instinctively, I would chop away at the extremities of my siblings, swinging wildly at their knees and ankles. Today, as I strive to finance their evergrowing need for assisted mibility devices I realize that the field of Neurology is my true calling."

Pathology: "As a second year medical student nothing could top the rush I had when reviewing a slide of a cirrhotic liver or an enlarged spleen. The pathologist serves as the doctor's doctor. And the doctor serves as the pathologist's doctor. Such is completed a neverending circle of interdependence the likes of which I can only dream of."

Plastic-Surgery: "I dream of a better looking world"

Orthopedics: "This table on which I write my personal statement is lopsided. Wait...it is no longer"

Urology: "I always felt people deserve two chances. Upon learning that there are TWO kidneys I understood my dreams had been realized. Oh, and urine...oh urine..."

Feel free to use any of the above in your personal statement. You need not thank me.

A Small Percentage

2005-09-15T12:16:00.000-04:00

I've been waiting for my two patients to show up for thirty minutes now. the only human contact I've had was a case I'm following. Today's case decided to discontinue all of his medications because he heard they could damage his liver.

"where did you hear this?"

It seems pharmaceutical advertising is having the beneficial effect of convincing patients that Death is not a suitable side effect. This makes the third patient this month who self discontinued his own medication. Well, you know what they say, patient rights.

"you know side effects only happen to a small minority of the patients taking a certain medication"

I bang my head at the wall, smile, bang some more. Why do they come to see me.

I've find this concept amazing. They come to see me. I give recommendations. They completely ignore my recommendation. And then they come to see me at the next appointment. I do my voodo spell, they feel all better. Completely ignore my recommendation.

"but doc, I don't want any medication that can damage my body"

And the search continues for the perfect medication that doesn't exist. I explain that it's a tradeoff. You take the bad with the good and you have to weigh the risk versus the benefit. I explain that I didn't get any last night, the wife had a "headache", the kid didn't sleep, she has a fever, I couldn't sleep. Please take your medication. I bang my head some more.

I Am Back, Baby!

2005-09-01T21:28:00.000-04:00

So, It's been a while.

September first today and this blog is 1 years old. It's officially the longest hobby I've ever kept. Judo lasted 7 months before I walked out in the middle of a session, learning french lasted 4 months, painting 2 months, tennis 5 months and the I can go on for the rest of this entry but I'll spare you.

Although I've been silent the last month I've been intending to get back to writing. Some really brutal rotations interfered. I'll post about these really soon. I also had some personal difficulties (nothing extremely serious) that I wanted to deal with and I needed a break from the blog or at least from the commitment to post.

Third year is so different than the second, I think mostly in the mindset. I'm actually starting to think about life as an Attending, finding a job, passing the Internal Medicine boards. Do I want to do a fellowship or not? If you remember I was a SYR (Second year reject) and so now I'm thinking about reapplying. I'de like to try for Cardiology. It would mean that I'd have to be a hospitalist for a year or two but the bright side is that I'de make some money before starting another ~~slaveship~~ fellowship.

Jordan is wonderful. She is becoming more interactive every day and she's such a daddy's girl.

I hope everyone has a wonderful Labor Day Weekend. I'll post when I return.

Some Responses to INTERNal Suffering

2005-09-01T12:44:00.000-04:00

It seems that while I was away some of my readers got a chance to sift through the Friday Ten Random Intern scut posts. In fact, some bacame upset with my impatience, my lack of respect for the fresh M.Ds. Responses included some of the following:

You are such a narrow minded, obnoxious jerk to take revenge on the hapless intern. Or are you taking it out on the weaker party for what you suffered when you were an intern yourself?

Wow, I hope this all makes you feel better about yourself

Reading your blog entries over the past few months, it doesn't seem like you have much respect or camaraderie for the nursing staff you work with- why is that?

I would like to remind everyone that the "hapless" intern discussed is a 25-30 year old adult who has an MD.

Each Resident cares for twenty to thirty patients for whom he is directly responsible. That is a lot of patients, think about it.

The math: Resident gets one hour to round on everyone so that's almost impossible. therefore, I am dependent on my interns to report back about the sickest patients. Since each intern cares for only 5-10 patients they should be able to see them all before rounds and warn me if a someone's condition is worsening.

The "hapless" intern (remember, 25-30 year old with a "medical" degree) forgot to mention that his patient was UNRESPONSIVE!!!!

That is a pretty large "forgot". That's Mega-LARGE.

Of course I spoke to him about it, of course I pointed out the obvious. No, this is not about how I suffered when I was an intern because my internship was rather easy. This is about responsibility. He just started his internship and I felt he was a little too lackidazical so he needed to be put back in line.

As for respect for the staff. There are good nurses and bad ones. There are good doctors and there are lazy doctors. I know who's who.

What I am trying to get across is that in our line of work mistakes or forgetfullness can have extremely serious consequences. Once you've witnessed a few of these you never really think about this job the same way again. If that's what I have to do to make sure the "hapless" MD understands that "nonresponsive" is a serious medical condition than that's exactly what I'll do!

Future Intern after her first central line

2005-08-31T00:51:00.000-04:00

See You Soon

2005-08-13T05:43:00.000-04:00

I've run into some difficult times both in my proffesional and personal life. When I'll feel creative again I'll return

Friday: Ten Random Things I asked My Interns to do Today

2005-07-29T15:52:00.000-04:00

Poor Intern. As Stated previously, said intern commited Cardinal sin #1 (The absolute worst violation) and is now in the dog house. Poor Intern (From here on designated PI) had an eventful Friday. I should procrastinate no longer and hereby list for you the Ten Random Things I asked My Interns to do Today: (Things PI had to do are *)

1. Discuss with the nurse if she can place a foley.
2. Place IV lines in three nursing home patients who have the most horrible, edematoud arms I've ever seen. *
3. Follow up blood test results.
4. Personally administer an enema. If that doesn't work...well...I'll let you know if it worked. Otherwise, poor intern. *
5. Confirm the size, shape and stage of the decubitus ulcers on the sacrum of said nursing home residents. They are quiet obese patients.*
6. Three rectal exams. *
7. Put together a good lecture on hyponatremia and the many causes of it. Make it a Powerpoint presentation.*
8. Review literature on Loss of conscience and come to a conclusion on whether this is an emergent situation.*
9. Insert a foley in a patient, himself!*
10. The enema didn't work...Poor Intern*

I wonder if he figured out what I was upset about?

Noah Got Upset

2005-07-28T05:37:00.000-04:00

As a reponse to my previous Comical post about how I joke with my interns and students. Noah wrote the following:

"Just jump on the orthopods. The IM docs are always claiming their intellectual superiority. Would love to compare the average board scores of medicine residents versus ortho residents. I'd bet we beat the meds by a standard deviation, honestly.And internal medicine is far more rote memorization than thinking. 90% of what you need to know you could look up in the Sabatine pocket medicine manual, and the other 10% you read before rounds on up-to-date. Evidence-based medicine nearly gets you off the decision-making hook in most circumstances. All you need to do is look it up.I guarantee that the orthopod's functional application of anatomy and biomechanics is on par with any internal medicine doc's application of physiology, immunology, or pharmacology to pathological situations.And kudos to ER docs, who can not only understand the important aspects of every field within medicine and surgery, but, unlike meds, don't shit themselves when a situation gets hairy".

Noah at vertical mattress

Rare as it is that I get a negative reaction like this, I took the oppurtunity to explain to Noah just what I meant:

"Oops I've managed to upset someone. We're all just joking around and this definitely shouldn't be taken too seriously Noah.I know that Ortho residents do better on their boards. I always feel bad because I feel that an ortho resident is like taking a new mercedes and driving it off-road. it doesn't make sense that they take the brightest minds for the job when I feel we can put their minds to better use. But I do believe you may have just taken me joking around with my interns a LITTLE TOO SERIOUSLY! I really don't think of Orthopods that badly"

On another note, evidence based medicine VERY RARELY gets us off the hook. There are studies to support maybe 40% of everything we do. The rest is all thinking and rationalization.

And, one more sidenote. I've been on the medicine floors for three years now, in the ICU for two, in the CCU for two and did four one month ER shifts. Not once "When the situation got hairy" (and it does often, believe me) did I pass any form of stool on myself. Like the post I wrote, this is also just hospital humor!

Update to Readers

2005-07-27T14:37:00.000-04:00

In light of recent events I thought I would update my readers on an upcoming attraction in the Mad House.

This morning, my intern commited cardinal sin #1. While in the middle of ATTENDING rounds he bursts out with "I don't know what's wrong with Ms. Simon, she's become unresponsive". The resident (a.k.a: Me) was not made aware of this earlier on RESIDENT rounds thus making RESIDENT look very BAD in front of ATTENDING! I mean "Unresponsive" tends to carry a 'bad' prognosis and really should and would have been looked into.

All this, and right before Friday's "Ten Random Things I asked my Intern To Do Today". I would call that...bad timing.

May god have pity on his soul this Friday. Because I won't!

Spectrum

2005-07-26T06:08:00.000-04:00

“Well, the thing is that I don’t expect you to do this well, I mean, you’re going to be an ER resident. You’re actually supposed to learn to do this wrong”
“Shut up you sarcastic dork”
“Just kidding! You’re not supposed to learn to do this wrong but just wrong enough”
“You act so high and mighty about your internal medicine”
“Well, I mean, internal medicine requires thinking”
“Oh and ER doesn’t?”
“Yes it does, don’t get me wrong. It’s just that as an ER resident you’re trained to come to the wrong conclusion. At least that’s my experience”
“Ohhhhh….I am so gonna kick your ass”
“Look, you should be happy. At least you’re not going to be an Orthopod like the Sub-I”
“Oh yeah…Where on your spectrum of intelligence does Orthopedics lie”
“Well, if I had to place Emergency it would somewhere in the middle, you know, does everything, just not so well. Maybe slightly above Rehab Medicine”
“Ohhhhh….”
“And Ortho. Well, I guess I would place Ortho slightly above…..Housekeeping”
“Oh, I am on service next month and you are so not getting a consult” Says the Sub-I.
“What do you mean, what if my car breaks down? We always need Orthopods to repair the cars out in the parking lot”
“OH! You are sooooo not getting a consult”

White Team.

PTT

2005-07-24T20:47:00.000-04:00

“What do you mean a PTT made you anxious?”
“Well, I just never had to face that kind of pressure before”
“That kind of pressure? Wait until it’s your post-call day and you’re exhausted and the admission from last night is going down the tubes and you can’t even remember your own name”
“That’s too much for me”
“THAT’S TOO MUCH? But you’re going into Emergency Medicine”

The look on the face of my intern made me realize just how innocent she really was, how little she knew and how little she worried. Still, no battle scars. The reason for my anxiety is that I realize things can get out of hand rather quickly. When complications happen they usually happen suddenly and only experience reveals the warning signs. The eye cannot see what they brain does not know. My intern has seen nothing yet.

I left her there on our post-call day after I saw all our patients. Helped her with a few notes and then I decided that my dues were already paid and that staying late on a post-call day is an intern’s job. I have no right to rob her of this experience.

On my way home the pager went off. It was the fourth floor and the lack of typical warning signs on the face of the beeper caused me to believe it was another nurse trying to reach me when she should be calling my intern. I had no way of calling back now and so I continued home. After arriving at home I found out that the patient from last night decompensated. I hear it was quick and chaotic. I also heard that my intern panicked. That she wasn’t ready for this and that the patient was rushed to the unit and later died.

The news didn’t surprise me. It was a patient who was really sick and it was certainly a possibility that she would crash. Somehow though, I don’t think my intern realized what I meant. Tomorrow she will.

At home I played with Jordan after not having seen her awake for nearly a week. And when the time came to bath her, feed her and put her to sleep I jumped at the opportunity. It was Jordan and I sitting in the spark of the nightlight in her bouncer. She was clean and sucking on her bottle and my thoughts waned and I remembered my intern. She is home now and she’s tired and her new life just smacked her in the face.

She’s wondering if this is really what she wants to do with her life now. Can she endure like this? Can she be a witness to such tragedy and be critical at critical situations. She is double-guessing everything she did today and likely herself.

As I sat there feeding Jordan I thought of my tortured intern. She must be going through shock but it will eventually make her stronger. But its misery now and it’s something she must experience. My intern was in hell and I looked down at Jordan and thought about the patient from the fourth floor. We were both in Heaven.

The Skeptic's Circle

2005-07-24T07:08:00.000-04:00

Check out the Skeptic's Circle over at Orac. Sad news, Nate no longer blogging.

Friday: Ten Random Things I asked my Interns to Do Today

2005-07-22T19:06:00.000-04:00

I'm back, rotation almost over.

1. Take a STAT PTT.
2. Grease the Radiology tech.
3. Draw various other bloods.
4. Transfer a patient to the unit.
5. Do an EKG.
6. Walk some patients around the hall.
7. Attempt to give her first patient the horrible news that he has lung cancer with metastasis to the brain.
8. Call for old records from another hospital.
9. Give me a massage. (a bonus)
10. Do a rectal!

Friday: 10 Random Things I asked My Interns To Do Today

2005-07-15T17:04:00.000-04:00

First, I intended to apologize for the very light posting on this blog as of late. I have some planned posts that I really want to write but this rotation is so brutal that if I get home early all I want to do is hang out with Jordan (Future Intern).

As I said, I 'intended' on apologizing but then I thought to check out some of the bloggers I love to read, as I haven't checked in for a while. I noticed Dr. Charles is on his little break, so is Orac. Maybe...maybe it's Summer, finally, and whatever time I do get I like to spend outdoors. So I will give a pseudo-apology for the light blogging. I will return when I get inspired or when I get enough rest, whichever comes first.

Of course, no Friday would be complete without the Ten things I asked my Interns to do today. So here goes:

1. I sent my female Intern with the big boobs to ask the interventional Radiologists to do a STAT PICC line. I apologize for my male shovenism to my readers. The PICC line was placed, STAT.
2. Go take a detailed history on a patient that I was supposed to present at a conference later in the day.
3. Discharge a patient.
4. Gave an assignment to do a future presentation on Hyponatremia.
5. Asked for a PTT on a patient every 6 hours. A very very hard to stick patient.
6. Transferred a patient to Surgery.
7. Push Social Work for placement.
8. Increased the dosage on a few meds.
9. Sent my student to get us breakfast.
10. A rectal exam.

Friday: 10 Random Things I Asked My Interns to Do Today

2005-07-08T14:46:00.000-04:00

1. Take a history on a patient he will not admit. (Made him quite angry)
2. reinsert an IV port.
3. Beg Bedboard to allow us to transfer a patient to another floor. (I sent chocolate)
4. Page surgery and pretend to be very upset about a patient on our service who's been awaiting surgery for a week now.
5. Discuss giving meds correctly with the nurse.
6. Order an Echocardiogram.
7. Order a Renal Ultrasound.
8. Call three atendings to inquire about their desired work-up.
9. medical student to draw blood on a patient.
10. A rectal exam. (My day is never complete without asking for at-least one rectal exam)

BTW, I neglected to mention that it seems my disciples are now spreading the madness. Look out for some more Madness coming to a hospital near you.

Poor Guinea Pig

2005-07-03T17:01:00.000-04:00

“So why do you keep drinking?”
“They keep opening liquor stores where I hang out”

That was a gem and it didn’t take long. It was only the second patient I saw since returning but I nearly lost my balance. I swear I could hear glass break. I bit my lips to prevent myself from laughing.

Then, another grenade:

“I once ate a battery”
“Why did you do that? Were you trying to commit suicide?”
“No. There were just all these batteries on the floor”

Yes, I know you’re expecting more of the answer but that was it. He stopped talking after that. There were just all these batteries, on the floor…

One day after returning from Israel I was asked to take over my team, learn all my new patients and be on call (ie: admit some more). My new interns are just so ‘Internish’. This could not have been me two years ago, no, no, it couldn’t be. The highlight of Saturday was trying to explain to my intern and my annoying third year student how to draw blood. Excruciating as it must have been to the patient who we were punishing for coming to the hospital in July. I was wholly taken back when the patient signed out a few minutes later, poor guinea pig.

Please don’t misunderstand, I have nothing against students, I even like them, a little. But there are a certain few who feel that they should pretend to know more than they do. This is a beneficial quality if it motivates the student in question to do research and to inquire, but it can also have the opposite effect. Specifically, if they finish off your sentences to prove they know the answer.

More often than not, they’re wrong. I understand that they want to impress me with how much they know but it has the opposite effect and just makes them look as if they’re unwilling to listen to a teacher. I have no expectations of third year students except that they remember what I’ve taught them and that they listen. This usually means that I expect them not to know anything, the first time. But that once I’ve taught them then they should know the answer. If you cut me off every time I’m trying to teach then I’ll simply stop teaching.

Overall, my team is pretty descent. I know a little something and my interns know nothing, yet. By the time I’m done with them they’ll know all the wrong things. Like how to pretend you’re working when you’re really not and Rule number 13.

It should be an interesting month.

Now, if you’ll excuse me there are these things all over the floor, what do you call them? Oh yeah, sharp razors…

Jetlag

2005-07-02T07:48:00.000-04:00

Stepped off the plane last night. Back in the Mad House today for a call. Nice to know life is just as hectic and irrational as when I left.

I have to say I actually did miss this place. This feeling of joy at returning will probably last until I meet my first patient.

Israeli Departed

2005-06-28T14:14:00.000-04:00

The new airport that recently opened here in Israel is spectacular. It's very reflective of the natural resources of its homeland. The rocks have a natural beauty and it's full of historical and religious articles displayed in shelving embedded within the rocks.

It's called 'Ben-Gurion-2000' and was scheduled to open at the end of the last century. After a slight delay of 6 years it finally opened and was worth the wait. It's huge and easily replaced the old airport, called 'Ben-Gurion'. As I walked through it I wondered what secrets it housed in terms of high-tech security. I arrived at this airport earlier this month to spend some time in Israel before starting my last year of residency.

I love this country. I've always loved this country. I was born here and I hope to die here one day. This country has everything anyone needs. It's got history, pride, tradition, variety, multinationality, scenery, soul, beaches, great food, great wine, and of course, beautiful women. The women are so beautiful that sometimes I wonder if it's really a holy war they're fighting here or just something more along the lines of Machismo.

It's so unfortunate that the people of the world only know Israel and the Middle East for the violence that occurs here. Rather, it's so unfortunate the violence occurs here at all. This place is so much bigger than that, yet, that's the first thought that comes to anyone's mind. Terror is the topic of the day. It rules the news; it rules the politics and life. Tragic and beyond comprehension to anyone who has never had the misfortune of witnessing a bombing, a mass murder of innocent lives. I've had that misfortune, I'd rather not discuss it now, it's really more along the lines of a horrible dream I've lived through.

It's so fascinating to me how in the middle of this chaos, this murder and this beauty, beats the hearts of a people that simply love. They love their country and they love each other. And, they have a character, a mentality that's simply hard to describe. This is a sort for impatient love. But it's so much more. It's ruthless and merciful at the same time.

My friend once described the difference between Israel and New York (where he lived at the time), he said "In New York they will pound you and pound you until you collapse to the ground and then they'll leave you there. In Israel they'll do the exact same but when you collapse they'll pick you up again". I guess it's the closest I can come to describing it. I'm sure some of you may disagree with me.

The mentality of Israelis is the secret and when I moved here to study medicine it took me a whole year to understand it. The best advice I received came from a Russian woman who cut me off at the local McDonalds in Haifa. She told me "The line in Israel is horizontal, not vertical". I came to learn the truth of that statement rather quickly. Most people would call that rude, I just call it "Israeli", and it always makes me smile.

Yesterday, I walked into a mall in upper Tel-Aviv. Of course, I had to endure the standard security measures as a security guard gave me a physical exam before I was allowed to enter. He jokingly patted my belly, since it protruded from my shirt and told me it looked "rather suspicious" (devilish smile). I told him I'll try to lay off the beers. We laughed, I miss that.

Last week we were on the beach, in a café. We ordered a Corona, and a 'strong' espresso. The waiter jokingly asked if there was any other way to make an espresso? It became a common theme and we began to order a 'strong' coke, a 'strong' salad. He returned quickly and gave us the Espresso, along with our 'strong watermelon', as he put it. I miss that too.

The past week was spent visiting old friends and family. Physicians I studied with who opted to stay here rather than return to the states. Friends I've had since I was a tiny toddler running around the streets naked in the sun. Aunts and uncles and grandparents who really want to see Jordan but pretended to miss me so I'd bring her along for the ride. It's been great but a rather exhausting week. I've been updated on the politics, the television, the books and the medicine.

The hottest topic of debate here are the settlements. Sharon would like them evacuated, as would the Palestinians and the U.S. Many see them as a barrier to peace while others see them as simply another excuse by the PA for delaying peace. The country is seriously divided over the issue. The clearing of Jews from their homes is heart-wrenching, even for those in favor of detachment. Soldiers are pictured daily in the newspapers as many tear off their helmets in defiance. They refuse to remove fellow Jews from their home. How can we judge them?

Along the streets people have taken to tying orange ribbons on their car if they are against detachment and blue ribbons if they favor it. Jerusalem is as Orange as a citrus Florida field, while Tel-Aviv is blue as the sky. The highways are a kaleidoscope of color. Debate, is the one constant here. It thrives in the hot air. But I promised to refrain from politics, simply because there's too much of it and I would not be able to do it justice.

For a country the size of New York this area generates news at a frightening rate. Israelis listen to the news incessantly. There's an update every hour and it's even played over the speaker system on the public busses. There's simply no escaping it. Not that you would want to, it's part of what makes this place so amazing. It's terrifyingly wonderful. Everyone is a politician and they all have three views on every topic.

This week I'm laying off the local events and concentrating on my tan, the beach, the pool and the alcohol. Let's not forget the watermelons. All I really ever wanted was just to relax and take a break before returning. You know a little sand, some beach, a beer and some coochi-coochi. Can it get any better than that? Oh well, at least I got some sand, a beach and a beer. Oh yeah, and some watermelon.

I Just Can't Stand It

2005-06-25T03:33:00.000-04:00

I'd like to think it's not because the hit counter daily average keeps edging slightly lower that I force myself to write an entry, so I'll continue to delude myself.

Since any such 'vacation' entry must be short and sweet (no sense wasting perfectly good sunshine) I decided to post some rules that I love-to-live by. Some of you may recognize these:

1. GOMERS DON'T DIE.
2. GOMERS GO TO GROUND.
3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
4. THE PATIENT IS THE ONE WITH THE DISEASE.
5. PLACEMENT COMES FIRST.
6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14 NEEDLE AND A GOOD STRONG ARM.
7. AGE + BUN = LASIX DOSE.
8. THEY CAN ALWAYS HURT YOU MORE.
9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
10. IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER.
11. SHOW ME A BMS WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
12. IF THE RADIOLOGY RESIDENT AND THE BMS BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
13. THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

Middle East Mission (Part 3)

2005-06-20T02:23:00.000-04:00

As I attempted to contact my handler one of the group's leaders (shown here) intercepted me. He attempted to drown me but after a long and valiant struggle I was able to fight off this "Resident". The information now rests with the United States government. What they choose to do with it is none of my buisness but I would not be surprised if this ends up in Guantanamo.

All US citizens should sleep well tonight knowing such capable espionage is being conducted and by none-other than the Future Intern.

No sign of Usama yet but I will not leave this Middle-East until all enemies of the American people are dealt with properly.

Middle East Mission (Part 2)

2005-06-20T02:22:00.000-04:00

I disguised myself with this bulletproof foam and penetrated an underground group called the "Residents". After obtaining their confidence, they entrusted me with the ultimate truth, one which I am confident the American public should know. The true Weapons of Mass Destruction are a group better known around the world as the "Third Year Residents". It is precisely these "martyrs" who have nothing to lose. Their commitment to long work shifts resulted in mind numbing sexual deprivation and they have become easy pray for promises of 72 virgins in later life. They must be stopped.

Middle East Mission (Part 1)

2005-06-20T02:21:00.001-04:00

Dear readers;

I was recently approached by the CIA to go deep undercover in a region currently in turmoil. I cannot specify the full details of my mission but I was sent to unravel the mystery of the missing WMDs and in the process I uncovered some critical information.

It’s Been the Best of Year and the Worst of Year

2005-06-13T10:30:00.000-04:00

My second year of residency has come and gone. It’s the one good thing about a blog in that it allows you to reflect on some of these experiences. Even better, it allows me to examine my progression and who I have become. Officially, as of eight this morning I am on vacation for the last two weeks of the second year, in essence, already a third year resident.

You’ve been there for it all. From my beginnings in the ICU and CCU and as I moved on to night float. When I had my own team and when I quietly served my electives. You've remember the Widow Maker and my trepidation. Times I was sure and others when I wished for divine intervention. Times I was ecstatic and others when I wished reality would leave, felt close to anoxia. You've shared my emotions and along the way cheered me on, some useful bit of advice, a kick in the pants. You pulled me from the mud, wiped me off and said “Go get’em Madman”.

It was a long and wonderful time, when I’ve witnessed my growth and changed in ways I never imagined. My thoughts meant all too much for me as I translated them to words. They became the experience. This forced me to take it all in. At times I wish I hadn’t. Paradoxically blissfully aware these are experiences others only dream of. Moments that change lives.

I’ve witnessed death in its most despicable form as it slowly drains all strength from those others depend on for life and inspiration. I’ve felt disease in its final stage as I pounded and electrocuted a father’s chest, trying to breathe life in. I’ve watched the monitor as a heart I cared for beat slower and then slower still until the pleasant rhythm ceased. I have lost many patients and with them many friends.

When I look back on the second year though, I would like to remember others who have neared death’s valley, who with our help, returned home to their loved ones. TYTD comes to mind. I helped them do that. Late on my twenty second hour I helped them do that. They will never know. Most probably, they will never acknowledge their near non-existence or my sacrifice, but when I look back at those days I will remember them and hope that they are making good use of their time. It is time paid for in the tears, sweat and energy of others who have come before and those who serve now.

Most of all I will remember this year for the biggest moment of my life and the beginning of hers. The birth of my favorite intern was my defining moment of Post Graduate year number two and I will forever remember it as 36 hours that transformed who I am. Today, I officially begin my vacation.

How I miss the Mediterranean Sea, its blue waters as exquisite and pleasant as the sand that lines its beaches. It’s been two years since I admired it from within.

Tomorrow evening I am flying to Israel for two weeks to join Future Intern and the wife who got a head start. I can’t think of a better way to spend my time then sitting on a beach chair with a beer on the side table, a watermelon on my plate and a little girl in my arms.

I may try to blog a bit while there. Maybe show some pictures of the nothing that I’m doing. I will refuse to talk politics or watch the news and there will be no medical blogging at all, sorry.

When I return, I will be a third year resident with all new interns. There will be new Chiefs and new Attendings and I will have to begin searching for a real job. That sounds amazing, a real job!

For now I hear faint whispers making their way through Europe and over the Atlantic. Aha, I recognize it now. The waves of Haifa beach are calling my name.

Le’Hitraot

Friday 10 Random Things I Asked My Interns to Do Today

2005-06-10T09:19:00.000-04:00

1. Turn a bedbound patient with no mental status over so we can have a look at his decubitus.

2. Clean off that same decub and put dressing on it.

3. Go hassle the CT tech to do a STAT CT on a patient we suspect had a leg clot travel to her lungs. I told him to take some chocolate.

4. Draw an Arterial Blood Gas from that same patient.

5. Smack the third year student for slacking off (Lightly of course!). It was a joke; Intern did it anyways. I’m so proud of her.

6. Call Infectious Disease for a consult. This is because I hate talking to the fellow on call that day. He’s such an ass!

7. Pull out a Naso-Gastric tube. This was one of the few happy things we get to do.

8. Put a peripheral IV line in a patient.

9. Get a urinary toxicology panel.

10. Sit down and enjoy the Dunkin Donuts and coffee I bought them for being awesome interns. We finish our rotation together this Sunday.

An amusing moment during rounds this morning when a patient known to shoot up with cocaine and heroin requested a central line so that we won’t stick him so often. That was funny!

The Skeptics Circle

2005-06-09T08:49:00.000-04:00

The first time I found Skeptico it was through a google search I conducted on a movie called What the Bleep do We Know. I was getting hassled by my family to watch it because they, again, felt it was scientific proof that god existed.

Skeptico wrote a good review of the movie. Needless to say, once they were made aware of these paradoxes the nagging disappeared, for now.

This week's Skeptic's Circle is hosted by skeptico (How appropriate).

Nasty Week

2005-06-08T23:26:00.000-04:00

As you might have noticed I've posted less than usual this last week, or at least nothing I consider substantive. This is because I'm in the midst of a dayfloat rotation. Which is kind of like a night float rotation except during the day (I hate to state the obvious). Tonight the wife and future intern left to Israel for a three week vacation. I'll be joining them next week when I get a much deserved break from the world of chaos I currently occupy. After that it's on to the third year of my residency. It will be my final year of residency but I will post a lot more about this soon enough. I just realized that it may end in me having to change the name of the blog, or possibly, find another Mad House.

While I'm away toiling with write-ups I thought I'd attempt to keep you entertained. This has nothing to do with the theme of this blog except that it's author found it very funny, so he decided to post it here:

"Dear Technical Support:Last year I upgraded from Girlfriend 7.0 to Wife 1.0. I soon noticed that the new program began unexpected child processing that took up a lot of space and valuable resources. In addition, Wife 1.0 installed itself into all other programs and now monitors all other system activity.Applications such as Poker Night 10.3, Football 5.0, Hunting and Fishing 7.5, and Racing 3.6. I can't seem to keep Wife 1.0 in the background while attempting to run my favorite applications. I'm thinking about going back to Girlfriend 7.0, but the uninstall doesn't work on Wife 1.0.
Please help, thanks
A Troubled User"

"REPLY:

Dear Troubled User:

Many men upgrade from Girlfriend 7.0 to Wife 1.0, thinking that it is just a Utilities and Entertainment program. Wife 1.0 is an OPERATING SYSTEM and is designed by its Creator to run EVERYTHING!!! It is also impossible to delete Wife 1.0 and to return to Girlfriend 7.0. It is impossible to uninstall, or purge the program files from the system once installed.

You cannot go back to Girlfriend 7.0 because Wife 1.0 is designed to not allow this. Look in your Wife 1.0 manual under Warnings-Alimony-Child Support. I recommend that you keep Wife 1.0 and work on improving the situation. I suggest installing the background application "Yes dear" to alleviate software augmentation. The best course of action is to enter the command C:\APOLOGIZE because ultimately you will have to give the APOLOGIZE command before the system will return to normal anyway. Wife 1.0 is a great program, but it tends to be very high maintenance. Wife 1.0 comes with several support programs, such as Clean and Sweep 3.0, Cook It 1.5 and Do Bills 4.2. However, be very careful how you use these programs.Improper use will cause the system to launch the program Nag Nag 9.5.Once this happens, the only way to improve the performance of Wife 1.0 is to purchase additional software. I recommend Flowers 2.1 and Diamonds 5.0.

WARNING!!! DO NOT, under any circumstances, install Secretary with Short Skirt 3.3. This application is not supported by Wife 1.0 and will cause irreversible damage to the operating system.

Good luck User."

Grand Rounds and the L.A. Times

2005-06-07T08:57:00.000-04:00

Never ignore your emails. At least that's what I learned today after catching the recent article published in the L.A. Times on Physician blogs. It features a few of my favorite blogs in The examining room and The prolific Oncology Writer. I do recall being sent an email to respond to but I ignored it. Figures it was just another Spam mail. Oh Well.

Having read the article I've come to realize something that I often forget. What we do is a mystery to people who don't understand medicine. This is easy to forget on your twenty third hour. In retrospect, I often do realize that what I do is "F*cking Awesome"! It's a mind rush I usually only get in retrospect, since I'm usually so anxious while it's actually happening!

So to get a better feeling for it go check out Grand Rounds. It's hosted by Medgadget this week.

Also, I wanted to direct your attention towards a new blog that's captured my attention. Imagine rounding every morning with the world? Enough consults for you?

Skeptical Agnostic

2005-06-06T16:52:00.000-04:00

In the last few years I’ve become the black sheep of my family. Mainly because, in contrast to my very religious parents and brothers, I am not a big believer and quickly trending towards non-belief. This often gets me into some heated arguments but I’ve learned that I won’t shake the faith of others and have become content to be left alone. Hoping every Friday that this subject doesn’t come up.

Recently, in another attempt to steer me towards salvation I was handed a book to read. The name of the book is “Permission to Believe” by Lawrence Kelemen. The author attempts to use a rational scientific argument to prove the existence of god. Too bad he uses the standard creationist arguments and incorporates truths in science with half-truths, sometimes even outright lies. A non-scientist would be non-the-wiser and would easily accept his version of scientific “evidence”.

I did, however, find his first argument interesting and I thought that the Skeptics Circle would be a good place to share it:

There are three attitudes one can have towards god. First, one can be sure god exists; such people are called ‘believers’. Second, one can be unsure of the existence of god, such people are called ‘Agnostics’. Finally, those who believe god does not exist are called ‘Atheists’. The author contends that only the first two positions make sense and that the third does not.

Can one be rational and believe in god? Certain events may have indirectly convinced him/her of god’s existence or that person has direct evidence of god. This is therefore a reasonable and an acceptable position.

Is it rational that one would be uncertain of god’s existence? Until one has direct or indirect evidence of the existence of god it is reasonable to remain unsure.

The author then contends that it is unreasonable to be an ‘Atheist’. Follow me:

He contends that there are three types of ‘Atheists’.1. A small group of ‘Atheists’ grew up in a home devoid of religion. Religion was a non-issue for them and therefore remains a non-issue.

2. Another smaller group of ‘Atheists’ were raised in a religious home and became atheists as a form of rebellion. They do not believe in god for emotional, rather than, intellectual reasons.

3. The largest group of atheists are those who examined the idea of god and could find no rational evidence for the existence of such a power. Most Atheists fall into this category.

Here’s the catch, since this third class of Atheist has never found any evidence to the absolute evidence that there is NO GOD (Since that is impossible) they must admit their position to be irrational and therefore must retreat to EXTREMELY SKEPTICAL AGNOSTICISM.

I thought the argument was interesting and so I thought I’d throw it out there for my second Skeptics Circle. I’m sure I’m setting myself up for an Orac rant, or another one of the writers I love to read, but I would enjoy reading their counter-arguments.

Number Seven

2005-06-05T11:19:00.000-04:00

This is the Future Intern and I decided to take time from my busy schedule to deliver my gratitude to the few bloggers out there who had comments about the previous post, specifically advice number seven. Yes, you know who you are. In fact, I so wanted to thank those few that I hacked into the Madman’s blog.

Seems my Resident upset everyone with good’ol #7. He thought he was doing everyone a favor he says “Just a few tips on how to coast through residency”. He didn’t even consider that number seven would inflame readers. He thought number eight was the gem of the post. What a dummy!

But I’m here only to explain that he probably was intending to say that if a patient has multiple complaints THAT DON”T MAKE SENSE, it is very likely that there is a psychiatric component and that maybe you should attempt to explore it. Not that one should completely dismiss it!

But you had to have your say. He comes in storming into the call room this morning talking about how this and that study proved this and that and that he was absolutely right.

So here’s where I express my sincere gratitude to those few altruistic readers who decided to point out the obvious. HE decided that I should write a post about it with proof that what he said wasn’t complete bullcr*p. Me! The Intern who just came off a twenty four hour call. Me!

Thanks everyone. I was only 72 hours away from a beautiful vacation after a year with a Resident otherwise easily confused for a lunatic and you get me assigned to a paper?

Sincere Gratitude, (%^$##*)
Future Intern

Friday Song List

2005-06-04T16:59:00.000-04:00

It seems every blogger these days is posting the friday shuffle list. Unfortunately, I don't have enough time to sit next to my CD player on fridays. So you'll never find this list here.

But, raise your sad little head young ones, I've thought of a more medical tradition. Every Friday I can list the first ten things I asked my intern to do that day. This way, you'll get to understand what it's like to be an intern and I get to reflect on how much it really sucked! Not to mention, it will certainly encourage me to get creative with my interns on Fridays.

I do remember one thing from my internship year: When your resident gets "creative" that's not a good thing.

Recommendations

2005-06-02T17:09:00.000-04:00

As the medical school year comes to an end hundreds of graduates prepare for the grueling year they’ve been anticipating their whole life. Graduations are celebrated across the country and the seniors, thinking about their fleeting time, come to realize that the now they must apply all they’ve learned in their new world, the medicine floor. I thought I would take the time to give the incoming class of interns a few suggestions I think will certainly come in handy.

The most important thing to remember is that like any other workplace the hospital is it’s own society, with it’s own rules. Each is different in that it has it’s strentgths and its faults. You still do not know most of these about your particular future place of work, no matter how many times you interviewd there. More importantly in the hospital, like the real world, it’s not what you know but who you know. If you want to be an effective intern, know everyone.

Let us begin, remember, the keys are in the details:

1. Most of medicine is common sense. You’ve heard this so many times and yet you don’t understand it yet. You will, later this year.

2. Don’t make your resident look bad. You will pay for that.

3. When you don’t know, find someone who will. This is really not about you. Anyways, we think you don’t know anything, regardless of what you really know. So take advantage of that.

4. You’ll hate the nursing, no matter how good it is. Understand, you will catch a lot more bees with honey. BTW, nurses can make your life hell so your choice will be smart and well-rested versus right and exhausted.

5. Having your own patients is so much better than seeing four new patients each session. This way, you will learn nothing. If you have a continuation clinic, know the months that you will be there. Schedule your patients to come back on those months. If your patient must be seen during a time when your not there, make a deal with another resident and send him your patient, so that he will send your patient back to you.Your patients will love you so much more for it.

6. Most of the time your diagnosis will be a symptom, that means, what you actually learned in medical school only applies less than thirty percent of the time. I’m not kidding!

7. If a patient has more than three complaints in one office visit the diagnosis is depression. There is no other diagnosis, don’t waste your time and our money.

8. You will need to bribe everyone. Since you can’t use money (You won’t have any) chocolate is the next best thing. You can move mountains with chocolate. (this is my personal favorite advice, consider yourself lucky to know this before you start, you can get any tech motivated with enough chocolate)

9. When you call a consult say “Hi, this is Joe Schmoe, intern in medicine” don’t say “Hi this is Dr. Shmoe” it just sounds more confrontational and is the key to a bad phone call.

10. Some operational alerts:
a. When a patient says he only drinks alcohol socially, your follow up question should be “How social are you?” You’ll be surprised.
b. When you ask if a patient smokes and he says yes your follow up question is not “How much?” but rather “What?”

Good luck guys. Remember, for any difficult question you always have two residents, yours and the MHM.

Grey's anatomy, First episode. and Grand Rounds

2005-05-31T16:48:00.000-04:00

I couldn't resist another Grey's Anatomy post. This sunday I saw the first episode (rerun) and it answered some questions. First, Miranda is a resident. Just a simple resident, which was a let down because with her attitude I had her pegged for Chief Resident. Now, she's too bitchy to be just a resident.

Second, they are supposed to have a seven year residency which I found strange since most Surgery residencies are only five years. But at least they won't have the same problem 'Scrubs' has with running out of residency years too early in the show.

I could see why the show caught on so fast. The first episode was a little better with Surgery handling Seizures and the usual Attending begging brand new interns to figure out what's wrong with his patients. Reminds me of my intern year when my Attending practically knelt before me and kissed my feet so that I would bail him out and mis-diagnose everything! (they're INTERNS).

the series opens with Meredith Grey sleeping with Dempsey. They act as if this is so casual they don't even know each other's name. Except this really doesn't fit with the Ms. Grey we've come to know. It's terribly out of character.

OK, no more Grey's Anatomy for this year. Maybe forever, the show really doesn't interest me so much any more. I feel bad switching to reviewing 'House' since others are already doing it. But hey, it's my blog.

Grand Rounds is here.

Update: Tangled Bank here

Cold

2005-05-31T07:49:00.000-04:00

We were married three years ago on a beautiful summer night in a kibbutz near Tel Aviv. I remember how beautiful my wife looked and how much in love we were (still are). We were inseparable then.

We recently visited a friend with whom I've lost touch. The last time we were at his home was one month before our wedding. The planning was beginning to take its toll but we still remained true to each other, inseparable.

He greeted us in his living room. We were shown into the house by his wife. We hugged and shook hands upon seeing each other for the first time since. When we sat down he broke into wild laughter and his wife's face slowly broke out with an infectious grin."What", I asked, "is so funny?"

"Well", he said, "I remember that when you two were here three years ago, before your wedding, you were sitting next to each other all the time. She held your hand, kissing it very gently and you wouldn't even leave her to go to the bathroom".

I wondered how that was relevant to his laughter. So I said "How is that relevant to your laughter?"

"Well, look at you now. Three years later and you're sitting on different couches all together. No more hand touching, kissing. Now you really know what it's like to be married."

I thought it was a funny observation and it reminded me of a recent thought I had after reading a study published on the infectious quality of the common cold. The cold is by far the most common complaint seen in a primary clinic. It is transferred by hand to hand contact and costs the U.S. a tremendous amount in healthcare costs.

The authors, attempted to study the infectious quality of this virus. They wondered what percentage of partners of individuals infected with the common cold would show symptoms attributed to the virus. Their results: 38% rate of transmitted infection.

Of course this is an average, which brings me to my next point. I would have loved to see subgroups incorporated into the study. Maybe stratisfying the groups into newlyweds, couples married >1 year but <3; and couples married for more than three years. I have my hypothesis on how the subgroup analysis would pan out. I think it would look something like this:

Newlyweds: Rate of transmitted infection 80%.
>1 year but <3 years: Rate of transmitted infection is 40%
Couples married more than three years: Rate of co-infection too insignificant to be detected using current scientific methods.

Try not to think about what my hypothesis says about my life.

Books for Sale: Look, I’m like Barnes and Nobles

2005-05-29T12:31:00.000-04:00

Those of you who have read this blog for some time now have witnessed my pathetic wining at the debt I’ve accumulated studying to be a physician. Likewise, my sad attempts at making a few dollars off this venture have brought you to the brink of nausea. Those who remember my humble beginnings with a blue template remember the Google ads that did nothing more than dirty my up my blog. Since the ads were guided by keywords they continually pitched “Residency Finders”. Too bad not enough foreign med students trying to find residencies read this blog. That whole attempt at profit grossed me exactly no dollars and no cents. Let’s call it “Unsuccessful”.

Now, I am trying once more but this time with something that makes slightly more sense. In case you haven’t noticed, I’ve installed an Amazon search box on this page. Its right below that long link list on your left (Go ahead, scroll down). Above the search box I’ve also listed a few of my favorite books. I thought I’d take this opportunity to try and pitch you some of these. If you like reading this blog I have no doubt you will love these books.

“Complications”
This book is a compendium of essays written by Atul Guwande”. Guwande is a surgeon and a master writer. In this book he writes about his experiences during residency. Each experience is a gateway into a discussion that explores the power and the limits of medicine. His writing is superb and he will give you a first hand view of what goes through a physicians mind when the going gets rough. That’s when one encounters “Complications”.

I highly recommend this book.

“The House of God”
To the medical personnel reading this blog I think this book really needs no introduction. If you like reading this blog, which began with a set up very much akin to the House of God, you will LOVE this book. It’s an extremely telling satire comedy about the state of medicine in the 1970’s. It’s funny, sad, emotional and a great read. It’s a book you won’t be able to put down without finishing.

I often make references to it and I’m sure that those who haven’t read it are left puzzled as to what my intentions are. This is your chance. This book is the bible of medicine and often gets quoted in actual practice, usually as a punch line, but nonetheless is a must read!

To the medical students or residents who have not taken the time to read this novel, SHAME ON YOU!

Tarascon Internal Medicine and Critical Care Handbook
The absolute best pocket guide for any intern or resident. It has everything you will need to know on an emergent basis. The rest can be studied on UpToDate.

Fear and Loathing in Las Vegas
This book is just a big’ol drug trip! After a long call, this book will do it for you.

Well, that’s my pathetic attempt at selling books. Again I’m reminded of why, after getting fired from my third sales position, I realized my true calling is medicine. I plan on changing them intermittently, whenever I get inspired to recall another great novel I finally bothered to pick up.

If none of these books picks your interest, well, just use the search box to find whatever you would like to buy. Of course, you can always go to Amazon and cut me out of the action. But, really, the price is no different there and that just means Amazon gets all the money. Why would you ever do that?

In case this doesn’t work I may just have to put one of those pathetic “Donate” boxes from Paypal on this blog. But that would be a real low and no one really wants to see me go there.

Happy Birthday Madman

2005-05-27T06:52:00.000-04:00

It’s my birthday today. It’s always during Memorial Day weekend. So, I hope everyone out there has a piece of cake for me, or a beer. Forget it, make it a good barbeque.

Happy Weekend everyone.

Great Reading

2005-05-26T09:18:00.000-04:00

today there are three carnivals that I'd like to inform you about. Lots of great reading for the weekend.

First, my favorite Skeptics Circle is up promising an enormous collection of debunkers! (your's truly, among them for the first time)

Second, The COTV is quite "alarming" (I'm sure everyone's been using this same line).

Finally, The comedy festival is up.

One of my Loves

2005-05-26T07:01:00.000-04:00

Last week's New England Journal of Medicine contains an essay written by Katharine Treadaway (Free full text here) that I thought I would share with you. She is an assistant professor at Harvard medical school where she teaches the patient-doctor course.

The essay is a reflection on her goals as the teacher of this course. Most striking, are the points she makes concerning the typical evolution of medical student to doctors:

I watch the second-year students file into the Ether Dome for their first day of my "Patient–Doctor 2" course. For me, this course marks their true entry into medical school. Here, they will refine their history-taking skills, building on their knowledge of pathophysiology and disease; they will learn how to perform a physical examination; and they will touch a living stranger's body as clinicians for the first time. For them, right now, these are just skills to be learned. They do not see how they will be transformed by them.

I remember my embarrasment during my first physical, I did everything wrong. I listened with the stethoscope to the heart sounds, then palpated the abdomen, went back to the stethoscope for lung sounds, then palpated, back to stethoscope etc. I suppose the crackles I heard in her lungs were really just quiet chuckling.

But was I transformed? I am more cynical than ever, more suspicious of others than before and more skeptical about what I hear. This is positive in a sense but it also makes for a negative view of reality. On the positive end, my understanding of the human condition (What people actually go through and endure) is so much greater now.

They do not understand the importance of what they learned last year, because they do not know how powerful they will become, how patients will hang on their words, how devastating a careless word can be. They do not know how they can "do everything right" and still be ineffective because their behavior has alienated a patient who therefore never returns or does not take necessary medication.

I think this point is just so important. It really never occurred to me until I heard my own mother recall what her own doctor had told her. Something didn't fit and so I contacted the physician myself. I learned that hearing is selective, especially my mother's.

Patients have so much respect for everything you say. Sometimes this doesn't come across in an encounter. One wrong word is all they remember. One chance is all you get, choose your words wisely.

Studies suggest that medical students become less compassionate by the end of medical school, that during the process of professional socialization, their original "commitment to the well being of others either withers or turns into something barely recognizable." In between, they have shifted their focus from the patient to their own learning process.

Is this universally true? Of course not. She’s right in that it happens to most medical students and residents. It’s a consequence of feeling overwhelmed with the body of knowledge one must master. It definitely happened to me as an intern. I’d like to think that as a second year it's resolving and that I now see patients as human beings, friends even.

To try to make it real for them before it actually is real, before they think that the entire purpose of taking a history and performing a physical examination is to develop a diagnostic plan and then a treatment plan, instead of understanding that this is only the beginning of caring for a patient.

Oh boy, I’m sure my medical colleagues can agree on this one comment: “Tell us about it!”

This is one of the extraordinary things about medicine, I say: it is an intensely intellectual endeavor, demanding that you learn and understand an enormous body of information and that you constantly update that information as new knowledge becomes available, but it is also an endeavor of your heart. At the same time that you are learning about disease and diagnosis and treatment, you are learning about illness, the patient, and yourself.

You will learn things about others that you could never imagine, good and bad. You will learn about the human spirit things which you will never be able to convey with words. Most importantly, you will learn places in your heart you never knew existed.

You will discover the bright and dark sides of your soul.

CSI Medlogs: What the hell happened to CodeBlueBlog

2005-05-26T06:34:00.000-04:00

Can anyone fill me in on the sudden discontinuation of one of my favorite blogs?

Grand Rounds

2005-05-24T06:36:00.000-04:00

A host of witty remarks, today, at the Chaplin

Prove it Prove it and I Still Don’t Believe it.

2005-05-24T04:09:00.000-04:00

This time I promised to make a submission to the skeptics circle. I’ve been debating who to victimize? Why, there are more than your fare share of scoundrels, thieves, and con men on the World Wide Web to fill Alcatraz seven times over.

Should I aim my wrath at the herbalists that swindle people’s money without a conscience? How about the homeopaths? How about the world of medicine? Why, I would never consider myself a con man. I’m a physician, trained at providing the best of care, using methods clinically proven to be effective, or am I?

We, as physicians, often discuss how medications should first be proven with appropriately conducted trials. To be more precise, what we mean is a trial conducted by a prospective double blind method. In english, that means the drug is tested over time with neither the physician nor the patient knowing whether they are taking the studied dose or the placebo/medication used for comparison. Thus, the design limits bias. There are a number of other trial designs, but that is another topic for another time. The double blind method is considered to be the most accurate.

But what would you have of a double blind trial that was designed well, limited bias, and showed a significant beneficial clinical correlation favoring a certain new medication. Should doubts continue to linger in a physician's mind or should he/she accept the conclusions as self-evident, absolute truth.

A physician or patient should seek one more critical piece of information, Where did the funding for the research come from?

The pharmaceutical industry now spends more on research in the United States than the National Institute of Health (NIH). Research that is unfavorable to the sponsor- meaning, trials that prove that the drug is less clinically effective, cost effective or safe than other medications used to treat the same condition, can pose very significant financial loss. This pressure may result in biases in trial design, outcome, and reporting of research sponsored by the pharmaceutical industry.

A recent systemic review in BMJ (Free copy available here) found that in research conducted by the pharmaceutical industry systemic bias favors the products which are made by the company funding the research. They found that their results applied across a wide range of disease states, drugs, and drug classes over at least two decades and regardless of the type of research assessed. The authors hypothesized four possible explanations.

First, companies may selectively fund trials on drugs that they consider to be superior to the competition. This is unlikely, since researchers could never predict results of trials in advance.

A second possible explanation could be that positive results could be the consequence of poor quality research conducted by the industry. However, the authors concluded that the research sponsored by drug companies is at least as sound as methods in research funded by other sources.

Other explanations include selecting an appropriate comparator. Often, doses of the medications being compared are not equivalent and a paper by Safer reported that in trials of psychiatric drugs the comparator’s drug is often given in doses outside the usual range or there is a rapid increase in the dose of the comparative drug, thus increasing the likelihood of side effects.

A final explanation suggests that publication bias may explain this finding. Research funded by the industry is less likely to be published than research sponsored by another source. Critically, the studies did not point out whether non-publication applied only to research with non-significant outcomes. The publication of these results would be harmful to the advancement of a new medication.

Most of the Giants (Older, wiser physicians) I know refuse to prescribe any new medication until it’s been on the market for at least 5 years. I believe that sounds like the advice of men who’ve learned their lesson. This brings me to the last and hardest to attain ingredient in making a great physician. Experience is everything!

Grey's Anatomy, Who's Zoomin who: A Resident's Review

2005-05-23T13:23:00.000-04:00

As I sat twitching while the writers managed, once again, to make a blunder out of what happens in real medicine I had a very illuminating thought. What if I stop considering Grey's Anatomy a medically oriented show and rather begin considering it as a world within itself, seperated from the world I live in.

I prefer to think of it as a spin-off from Desperate Housewives. I mean, what is the real difference? Everyone is sleeping with everyone.Its a sopa opera within itself. It's own imaginary world.

Shall we explore this world:

In Seattle Grace Hospital Surgery is the only residency. This is why Surgery must handle all medical issues. In Seattle Grace Hospital there is no medical hierarchy, there is no accountabiity, interns do Everything without supervision. Attendings sleep with interns, the staff sleeps with everyone and surgery interns are so friendly that they feel perfectly comfortable discussing masturbation, sex, and even strip naked, at every oppurtunity, in public. None of this has any consequence on their proffesional reputation. In the world of Grey's anatomy, when hearing hoofbeats, think Zebras. I love this world. Oh why can't the Mad House be in Seattle?

The season finale seemed more about the internal conflicts than about actual medicine. It was intended to make sure we come back when the super-six return for a second season.

1. Mr. Fragrin and the Cirrhosis.

In Cirrhosis of the liver scar tissue replaces healthy liver tissue. Most commonly this happens as a result of alcoholism but other, more rare diseases, can cause it as well. Due to the decrease in productions of proteins by the liver Ascites often results, a condition where fluid accumulates in the peritoneal cavity, the abdomen. Yang and Izzy perform an abdominocentesis and the patient dies during the procedure. In order to prove that the death was not of their doing they perform an unauthorized autopsy.

Paging Surg-path intern you're needed in the morgue! (For the death of your own career).

These 'expert' pathologists discover that he had a condition also known to cause cirrhosis (much more rarely though) called Hemochromatosis. It is a genetic disease that causes excessive absorption of iron from food. This iron accumulates in the liver, pancreas, skin and heart and can cause Cirrhosis, Jaundice, Heart Failure and Diabetes (Often called 'Bronze Diabetes').

It's much more rare than alcoholism but we must think Zebras. For fun, I suggest attempting to perform your own unauthorized autopsy. I take no responsibilty for what happens.

2. Gonadal Hermaphrodism: A case of a man, Burke's best friend, who presented with hematuria (microscopic amounts of blood in the urine) that led to a cystoscopy. During the procedure a mass was found that was later diagnosed as an ovary.

The condition is a congenital defect that is present at birth. The genitalia are usually ambiguous and these children need surgery to correct the appearance. A finding such as this in a thirty year old male is unlikely in that he would have surely known about his condition.

The story gets more convoluted for drama, his wife is pregnant. His condition makes it impossible for the baby to be his and so Burke discovers the wife's infidelity, which he now must disclose. Talk about a bummer? how would you like to find out you have ovaries and a wife who cheats. Poor Burke doesn't know he's got a doozy coming his way next season!

Paging Surge-Psych!! Surge-Endocrinology! Surge-gyn!
Paging some sanity in an impossible world.

The story of Yang's pregnancy doesn't really continue. We are left to wait for next season.

As for Dempsey and Pompeo (Meredith), the last scene is a cliff hanger as Dempsey's wife spontaneously appears and says to Meredith:

"Hi, I'm Mrs. Shepard, and you must be the bimbo who's screwing my husband!"

Ouch!

I bet they're seperating, otherwise, why would Dempsey be sleeping in a trailor?

BTW Ms. Pompeo, my wife hates your eyebrows. Sorry, she made me put that in.
Until next season, this is the MMM signing off on my round-table of a mediocre medically oriented soap opera.

Dangerous, Do not Touch

2005-05-22T09:08:00.000-04:00

Recent evidence shows that physicians are less likely to report errors made in the course of patient treatment. The reason most often cited for this lack of reporting was fear of legal action. Thus, this has become a significant obstacle in improving patient care and working towards safer and more efficient methods. Recently, many programs began implementing anonymous reporting systems as a way to circumvent this fear, in the hope that reporting of adverse events would increase.

The program director of the Mad House Medicine Residency program announced that he would install a reporting system on our residency website. The system would be completely anonymous and would allow the interns and residents to report situations in which patient safety was endangered in various ways. It was, after all, a relief. A system of instituting interventions which ultimately will lead to less morbidity and mortality.

But then how was I expected to restrain myself from reporting what I know to be the greatest danger in our hospital? Believe me, I tried. But unfortunately, one day after the system was instituted, much to my dismay, I found myself writing an email that clearly explained what I thought to be the most threatening factor to the future health of my patients:

“Medical Students, Interns, Nurses, and Me”.

Grey's Anatomy Season Finale Tonight

2005-05-22T09:05:00.000-04:00

The last two weeks have included the best of Grey's Anatomy and then the dismal bottom (or so I hope). Tonight is the season finale, review tomorrow. I hope for a good show.

God what if we couldn't inject morphine for the pain? how in the world would we dull the agony of residency?

2005-05-22T06:14:00.000-04:00

It's Morphine's 200th birthday. Go to the party.

Go Laugh

2005-05-20T21:58:00.000-04:00

I know I've been kind of light on the medical comedy lately. It's not that I can't think of any it's simply that I've decided to outsource. So go have a good laugh at the Carnival of Comedy. Somehow, my entry was intercepted over the world wide web (I'll give the host the benefit of the doubt for not including my entry). Well, there's always next week.

The Carnival Introduction Tradition

2005-05-19T09:51:00.000-04:00

Staying true to my Tradition of wrapping up any Carnival hosted here it's time to do a roundup of the most interesting introduction links written by my fellow bloggers.

I have to be honest in that I really didn't like how the Carnival turned out. I've been thinking about different themes for about two weeks and after trying out three different themes (Which came out horrible) I scrambled to put this one together in the last minute. On the whole, I think it came out interesting but I wish I would have thought of something more creative. I'm kicking around the idea of hosting the Carnival of Comedy but it'll be a long time from now (I am tired!).

Hosting a Carnival is no small task. Thirty entries take time to read and, honestly, some are really not "up my alley". Which means I either misunderstood the piece, didn't have the expertise to judge whether it was true at all (which is probably what happened with the Einstein God piece that's getting objection for being included), or, really wasn't very interested. Mostly though, I did enjoy the majority of the entries.

So on to the fun task. First up:

Orac linked with this entry:

"Hey, wait a minute! Debunking quacks and dubious alt-med is my territory! (OK, it's also the territory of Peter, Anne, Paul, Skeptico, and others, and I know I've gotten derailed a bit dealing with "intelligent design" pseudoscientists during the last couple of weeks. Don't worry, though, the alt-med stuff is coming again next week.) And, worse, the Mad House Madman is funny about it. Now I remember why I stole his idea for an interesting and unusal format to do Grand Rounds when I hosted my first blog carnival way back in February. Damn. If I had known the Madman's intent, I would have submitted this article instead of the article about the risks and benefits of phase I oncology trials that I did submit".

So there Orac, you just did submit that link. Anyways, I love most of your entries so I have no problem hosting another post of yours.

Although debunking alties isn't exactly my territory I am hoping to make it into the next Skeptics Circle. Heck, maybe I'll just submit the Tangled Bank for it. I hope to come up with something original to debunk, but I'll start slow. For now, I've debunked the fact that your the only debunker in town (except for Peter, Paul, Anne, and Skeptico).

St. Nate:

"And, once again, the Madman has taken a very creative approach to the project and arranged them like a row of alternative medicines. Yeah, he's crazy, but it's a fun kind of crazy".

Depends who you ask. Some of my patients don't think it's so "fun". But I hope you do.

BTW, I have absolutely no idea how Nate, Orac and Charles were the first entries. I mean they gave their submissions in so late, except for Nate. Really, how in the world did they end up at the top?

And I loved this one (Great Job) 10,000 birds:

"If television has taught us anything (and hasn't it taught us so much?) it's that medical professionals lead tragic, tortured lives. Misanthropic Becker, bitter House, and the agonized souls in the E.R. all explore the depths of human misery, their only crime presumably being that they care too much. Bearing the weight of the world on your shoulders and a stethoscope around your neck clearly takes its toll. Bones McCoy was gripped by a Messiah complex, Dr. Bombay of Bewitched obviously suffered from syphilis-induced dementia and Quincy was ostracized by the medical examiner community because of his closeted relationship with his finicky roommate. Further examples of doctors, nurses, and dental hygienists ruined by their profession are legion, at least on TV.

The Mad House Madman of Chronicles of a Medical Madhouse is obviously another casualty. At this stage in his career, this second year resident seems to have already cracked under the strain of medical practice and has been reduced to peddling dubious wares via the twenty-eighth installment of the Tangled Bank. By all means, you should examine this fascinating case study".

I just love it.

That wraps it up. If I had to pick a site I discovered from the Carnival that I just love reading it would have to be Mindhacks. I'll add it to the sidebar, somewhere.

Tangled Bank #28: “Alternative” to a Healthy Mind

2005-05-18T07:05:00.000-04:00

Welcome to the Tangled Bank, a carnival that’s everything scientific. The Tangled Bank has evolved over the year to include medicine and topics closely related to science. The Medical Mad House is proud to host this wonderful carnival in what we hope will be another success.

We wanted so badly to be original that we decided to highlight, for the first time in Tangled Bank history, some of the more questionable practices of medicine. We therefore reached out ot the homeopaths and the herbalists for submissions. Quickly, we learned how to swindle people's hard earned money ourselves and developed our own Mad House line of products. If you would like to purchase any please email me at I’m_a_sucker@Madhouse.com

I encourage you to read all the entries as most of them were well written and very interesting. The highlighted link is the only part of the introduction that's related to the post. Don't understand what I mean? Read on.

But remember, I am a second year resident, which automatically denotes a certain amount of residual psychiatric pathology from internship. So if you don't love the "theme", blame it on the haldol.

Shall we begin?

St. Nate's All Natural Olive oil and Garlic Mix
This first line agent for life threatening disease has never failed in clinical trials (We’ve never conducted any). Our medical expert, the health minister of South Africa, recommends the supplement to cure AIDS in his country. Look at the great results he's getting.
Side Effects: Stupidity, Lunacy, Delusions, and Dying of AIDS.

Dr. Charles Green Man Stone Carvings
Sure to reconnect you with Mother Nature, you will feel soothed and naturally cure hypertension and diabetes. Simply crack one of these over your head every morning.
Side Effects: Hemorrhage from cranium, epidural bleed, subdural hemorrhage, contusions, and induced mental retardation.

Orac's Phase I Easy to Swallow Powder
Ever wanted to know how Oncology Phase I trial are chosen and conducted. This essential remedy contains mountain daisy and marsh tea and is proven to cure resistant cancers. My grandmother's sister's husband's former roommate from college knows this guy who was instantaneously cured by this stuff. Really!
Side Effects: Advance in Stage of Cancer. Loss of internal organs unnecessarily

Andy's Natural Killer Cell Evolutionizer
This anti-pathogen cream is made of an Epstein Barr Virus solution combined with poison Ivy in large doses to boost you body's Natural Killer Cell population. Didn't know you had Natural Born Killers? Sexy isn't it.
Side Effects: Lysing, complement fixation, spending excessive efforts engulfing or just golfing.

The Milkriver Xeric Snail Complete Kit
A medicine par excellence to cure the possible decline in this magical species and will increase your enthusiasm for life and give you that energy you've always wanted. You will magically lose weight when combined with appropriate diet and exercise.

Einstein God's Darwinian Supplement
Feel unable to respond a creationist appropriately? Simply omit Spencer from the argument and this supplement allow you to think more freely and rationally.

Bnug Ferret Cocktail
Specially engineered to combat nausea or induce it (we're not sure).
Side Effects: Retching, Vomiting, Nausea, Wishing for death as you hover above your toilet so that it will all end.

Kelly's Fluoride Flavored Powder
When given in small doses can be toxic to tooth-decaying bacteria. Recently it was discovered as a toxic compound, did you know this? Neither did Kelly. We’ve decided to change marketing strategy and sell it as insecticide.
Side Effects: Insects with clean teeth.

Circadiana Circannual Rhythm Chant
Ever feel tired after strenuous exercise or a large meal? Chances are your circannual clock is not accurately functioning. The Chant (Melody and words sold separately) is meant to be sung in public and is known to increase the amount of riboflavinoid Manisticast in muscle.
Side Effects: Appearing unintelligent, Psychiatric hospital admissions, possibly some jail time.

Technogypsy Soda Pop
Wonder how much science goes into making a simple soda bottle? Simply buy this drink and place it on to increase your taste bud sensitivity level and waste your hard earned money.

The Harvester Butterfly Compound
An introduction to this magical species of carnivorous butterflies. The shell of this former caterpillar is ground and mixed with “ultra-plasma”. Also buy Harvester stool, which is known to have a high percentage of gastroflabric flavinoid, a first line agent in fracture treatment (you must first get the fracture cast first)

Bootstrap's Ivory-Billed Woodpecker Wood Extract
An account questioning why the US government doesn't help the Woodpecker where they do know it exists? A pure extract from Cuba made from bird droppings. Guaranteed to not be guaranteed.

Political Calculations Easy Math Memory Tape
This book by Political Calculations on the easy to memorize mathematical system of calculating GDP will allow you to forecast the exact point at which this administration will drive the Gross Domestic Product into the dirt.
Side Effects: Bankruptcy and Property Seizures. Death by Uncle Sam.

Canadian Cynic Creationist Complex (Quad C Mix)
The magic quad C mix is made of marigold and Comfrey and was “directly observed” to be quite ironic.

Evolgen Chimeric compound (ECC)
What is a Chimeric gene you ask? The optimal treatment for deep cuts and bruises. This extract works wonderful, after stitching.
Side Effects of ECC are mild and include death, coma and persistent vegetative state.

PZ Myers Sea Monster Cream
What do you think of when you think of Kansas? The Niobrara is a geological formation where we found these special gems made to help with your typical this and that and give me your money.

Brentrasmussen Human Origins Cleansing Enema Treatment
By learning the origins of the hominids (that, hopefully, is you), we’ve discovered a liquid that’s equivalent to a deep rectal massage. I will save you the gross details.
Side Effects: Gross Details

Feministe Female Orgasm Original
A soy based formula to help your possibly useless female orgasm and designed to stimulate and indulge the mind’s more erotic centers. Work when used in conjunction with good sex.
Side Effects: Let's face it, even I would buy this.

Rhosgobel's Antibiotic Resistance Resistor
Know how bacteria acquire resistance? No? We can definitely sell you some of this useless crap then. Made of seaweed and salmon serum it’s designed to protect bacteria from the damaging effects of antibiotics, and useless other things.

Blogology 101 (Great name BTW) Pundit Silencer
Just load this wonderful pistol and aim it at your television next time some science pundit appears on MSNBC and says a whole bunch of crap that's not true. Now, pull trigger!

Aydin Stupid Mummy Recipe
Investigation into Mummy curses have led to an interesting finding. We just don’t have a pill for it, yet!

Sound and Fury Dark Matter Combo
What fills the galaxy? An extract to improve dark matter vision, it will open your eyes to the wonderful world of astrology. The only downside of this wonderful extract is spending valuable time thinking about astrology.

Ware Farms Genetic Sexual Device
Since Sexual orientation is coded for in genes we've invented this easy to carry Quick Sexual Orientation Analyzer. Easy to afford in 3 simple payments of $89.99.

10, 000 Birds Sexual Dimorphism Decoder
Ever felt like your hubby was better looking even though he's also human (I hope)? Now you need not wonder why. The process is called sexual dimorphism and if you buy this decoder absolutely nothing will happen.

Organic Matter Wollemia nobilis Resurrector
Stumbled across an extinct species recently? Once Believed to Be Extinct, Wollemia Nobilis may just be your key to the next great discovery. But it’s unlikely.

Vaughan’s Depression Pick-Me-Up Workout Tape
Some scientists have determined that depression is a "physical disease". Duke Tightbutts, famous celebrity trainer, will help you squeeze and flex those blues away. Take control of your life, your mind, body and your bank account.
Warning: wearing tights may make you look silly enough to push you into further depression.

B and B GIFTS Package
Ever heard of Geosynchronous Imaging Fourier Transform Spectrometer? It’s a NASA mission that led to the discovery of our holy crap I’m drained out of ideas and this theme is long past overused. It’s a great article, read it.

Joshua Starling Prepackaged
A Starling grapples with a predator. Since starling are evil we can’t use them in any of our "medications", I use that term loosely.

Cameron offers a variety of computer projects others can participate in. He calls it computer research.

Dave's Drum Machine
Demonstrating how tempo changes mood and an interesting experiment that showed how drummers convey different emotions buy simply changing the tempo and volume of a drum.

So feel free to celebrate life to the sound of a different drum.

That wraps it up. I would like to thank all thirty contributors for taking the time to write such great stuff simply for pleasure. I had a wonderful time reading your entries. Thanks to PZ Myers for letting me host the Carnival. E-mail host@tangledbank.net if you would like to host or for submissions. The next Tangled Bank will be hosted on June 1st at Organic Matter.

Finally, when I was in eighth grade a banner hung above the blackboard. It was a quote by William Harvey and it read "All that is known is infinitely less than all that remains unknown", so get to work.

At the Front

2005-05-17T22:42:00.000-04:00

Future Intern wanted a front row seat for tomorrow’s Tangled Bank. How could I say no to that face.

Tangled Bank, Last Call

2005-05-16T18:09:00.000-04:00

Last call for the Tangled Bank. All submissions should be in by tomorrow 6 pm EST.

Suddenly there was a tremendous inflow of submissions. Way to go guys, better late than never. I have them all. It should be a good one.

See you Wednesday.

Gray's Anatomy "Save Me". A Resident's Review

2005-05-16T12:29:00.000-04:00

I am contemplating changing series. Maybe, I'll begin to review "House" or some other medical oriented show, something on cable.

I really don't even know where to begin last night's overview. It was just so bad. Just so terribly bad. I know I repeated myself, it's really from the overwhelming disgust that something so abundantly misleading could ever end up on network television.

How were any of these patients placed on the surgery service? Did they ever hear of "Internal Medicine" at Seattle Grace Hospital? Apparently not.

Opening Scene: Pathetic.

Dr. Shepard (Patrick Dempsey) wakes up at Ellen Pompeo's house with her fellow interns. He goes to the kitchen and eats breakfast with them. Everything is soooo cool and mellow. Yep, just your typical Attending sleeping with intern in over at other intern's house. Yo dudes, whussssuuppp!

Simply put, NO! If they only understood how ridiculous that entire scene seems to medical personnel. It undermines any last inkling of authority this Attending would have.

No further comment on this plotline, it's a real loser for me and highly unrealistic.

Lets get this over with:

1. Orthodox Jew with Presumable Endocarditis: I say "presumable" because no one ever specifically states she had endocarditis. They say she had a dental procedure, then a fever, and now she needs a new valve. I'm assuming it's endocarditis. It's a recurring theme with this show where we have to guess the diagnosis. Like the unknown "advanced carcinoma" (we'll get to that soon) so I'm guessing the budget is too tight to bring in a medical consultant who can spell the diagnosis and teach them how to "pro-nou-nce" it.

The writers/directors screwed this story up so royally. First, endocarditis is an Internal Medicine case. Second, I am also an orthodox Jew and have never even heard of such a RIDICULOUS argument as to say that a porcine valve would be unkosher. Seriously!

Third, if you decided to make her orthodox, even have an outright argument with her parents during the show about the merits of reform Judaism then she would need a MALE rabbi, as one of the BIGGEST differences between Orthodox and reform Jews is the fact that the former does not accept females as rabbis.

Next horrible story line:

2. Seizures/Psychic man with the AVM: AVM stands for Arterial-Venous Malformation, it is the main cause of most subarrachnoid hemorrhages, a specific type of stroke. I will be brief with this one:

Seizures go to Internal Medicine. Surgeons don't do seizures. Surgeon's also don't do psychiatric clearance. Psychics don't really exist. Is this a medical show? I'm starting to have doubts.

Ms. Glass. Invasive "Carcinoma":

3. WHAT TYPE OF "CARCINOMA"???

Really, I'm getting more upset.

Mainly to highlight Chang's own conflict with her pregnancy this patient had the choice between her own life and termination of her pregnancy. Would have been a really interesting case, maybe deserved a little more attention. Could have used a lot less of the ridiculous couple.

however, The show's apparent need to be as non-specific as possible is harmful since it perpetuates the common misnomer of "Cancer". There are different types of cancer, each with it's own form of treatment, it's own prognosis.

BTW, Were they planning on calling Obstetrics? Really? You think you should call OB? Naaa....Why in the world would you ever call OB? C'mon, you're a surgeon.

Thank goodness this is the last one:

Mr. Walker and the ascending paralysis.

Tthis case was ridiculous. A Neurologist never sees this man, Guillen-Barre (The most obvious diagnosis) is never entertained, the MRI is negative and Dempsey drags this man into the OR and opens his spine, just to prevent intubation.

Wait, let's examine how surgeries are done: Pt goes to OR, pt gets placed in position, patient is INTUBATED!

Let me help you with this "pro-noun-cia-tion", can you say "mal-prac-tice"?

No wonder people misunderstand the way modern medicine functions.

Last night show was deplorable.

Grey's Anatomy "Save Me". A Preview

2005-05-15T23:00:00.000-04:00

Of course tomorrow I will write a full review so don't chime in with your comments just yet (Save them so we rag together). I just wanted to lay out all the things I loved about this week's show in a well arranged, well thought out list:

1. Well...The show eventually ended

Meanwhile, why don't you go learn a little history at the History Carnival. Nate's Hosting.
Or...you can piss away all your time with posts that will not make you one bit smarter at the Comedy Festival at IMAO.

So which one will you choose.

Stop PISSING!

I've Been Upgraded

2005-05-14T00:25:00.000-04:00

Just noticed that my status in the TTLB Ecosystem just upgraded overnight to Marauding Marsupial.

Marauding: "To rove and raid in search of plunder"

Marsupial: "Any of various nonplacental mammals of the order Marsupialia, including kangaroos, opossums, bandicoots, and wombats, found principally in Australia and the Americas"

I would like to thank everyone who links this page on their blogroll. I'm proud of my little achievement. Now I'm a roving Kangaroo. Maybe I'll change the name of the blog to "Roving Kangaroo". Naaaaa!

With the Tangled Bank coming and PZ checking out the site once in a while I'm happy to know I'm escalating on the evolutionary ladder.

Update: I've been downgraded again. Who deleted his link? (As they say on south park: You Bastard!)

The Skeptics Circle

2005-05-12T20:17:00.000-04:00

I try not to make too many of these one liner entries but this is a carnival I've really grown to love. The writing is often great and the topics are so interesting. You can pick and choose, of course, but I'm sure it won't let you down.

I've been wanting to hand in a post for the longest time but couldn't come up with anything to write about. I guess I find I'm not that skeptical. Even when I do find someone who truly annoys me with some off base comment I often react very poorly:

"What the hell are you talking about?"

Or something like that.

I don't have the patience to sit and debunk their theory point by point. I often leave that up to the experts, my Skeptics Circle.

My next goal is to debunk something. St. Nate is hostin the next circle and in addition to being one of my favorite sites he's the one who began this whole thing in the first place. so I will make my debut there, I've decided.

This weekend I will be working on the Tangled Bank. Get your entries in because nothing drives a man more nuts than last minute integration. And I'm already crazy!

Dear NBC;

2005-05-12T07:09:00.000-04:00

Recently, I’ve taken the liberty of reviewing medical television shows. I was not appointed this position by a higher power, no; I simply assumed the project as I realize it is missing from the blogosphere. During this time I have grown enough confidence to believe that my opinion counts and that often it is dead on accurate. I believe that my readers would tell me otherwise. I am turning to you in a desperate attempt to save the few fond and warm memories of a show I once loved.

When ER first aired it was a tremendous sensation. We were introduced to a staff of physicians who seemed to have a higher purpose. You showed us the intricacies of emergency medicine, trauma surgery and even departmental politics. The weekly compendium of complications and resuscitations were exciting, and at the time, different from anything we've seen before.

I still remember relating to Noah as a medical student, and how irate it made me when he, and all the other med students, always knew the answer. But I loved him no less. Yes, I even remember Lucy and the tragic end.

I can safely say that you alone have inspired a whole generation of wanttobe doctors. Many of my fellow residents owe their dreams solely to your show. Which makes what I’m about to write all the more difficult.

It is with sad tears that I say this to you. Not like an unwelcome stranger but more like a Forty year old son still living at home:

You have overstayed your welcome.

One too many codes, a few too many psychiatric rages, motor vehicle accident victims, medical students dying, burned out nurse stories. Too many child abuse cases and way too many physicians from past episodes unexpectedly popping up and mysteriously returning to full time posts.

Let’s face it; the original cast is long gone except for Noah Weiley. It’s like watching Guns and Roses after all the band members left to rehab, or died in their own vomit. Maybe a sports analogy would be more appropriate. I think the closest would have to be watching Micheal Jordan in a Wizards uniform. Yes, it was Micheal but you just felt sorry for him. It was unbefitting.

That’s kind of how I feel when I watch your show now, I’m disgusted. You’ve managed to take all the love I had for you, you spit on it, threw it in the mud and stomped on it incessantly.

I was sure that after the episode with the helicopter crash through the ER you would have thrown in the towel. Alas, I was wrong. I was horrified as you continued to return for more abuse. I now have no more pity on your soul. To me you will always be a constant reminder of how Seinfeld did it right. Couldn’t you learn what he was teaching? He wasn't that far away, only one half hour separated you both. You must have been aware of the concept, go out on top.

Now as Noah is finally about to leave you must come to this same conclusion. What is ER without Dr. Carter? We’ve watched him grow from a medical student. We’ve endured his drug addiction and now, even he is leaving you.

This is a sign. I beg you. Stop!

More Medical Blogs Reviewing Medical Shows

2005-05-12T07:08:00.000-04:00

I happen to run across this review of House from Polite Dissent.

COTV

2005-05-11T18:52:00.000-04:00

at Cynical Nation