Sunday, September 30, 2012

Abs Suffer

It's just not enough hours left in the week at the end of an 80-90 hours work week to do the things you need to do. I spend most of my days off doing wash, shopping and the like. I get to the gym infrequently and wonder why I can only aspire to the abs I dream of. Residency makes the abs suffer, no doubt.

P.S. Not the abs I aspire to get, but since she won Olympia 2012 Bikini, they are worth admiring. And I don't have a belly button ring either. Not yet anyway.


It's time to just make the evaluation of diseases related to smoking no less or no more than drug abuse. Everyone should be tested and held to the same standard as addicts of any other kind of drug abuse. Our response in medicine should not be predicated on legal or illegal but mass net effect on the body and on the system of care we provide.

And while we are at it, stop all government subsidy of any substance that causes lung cancer, COPD, asthma, stunts growth and makes you smell so badly.

Saturday, September 29, 2012


I slept in today for the first time in ages. I feel guilty for getting solid 7 hrs, and I shouldn't.

Sleep is an active process where the brain works to heal the body by producing hormones beneficial for repair and growth. 

This is also the time for the brain to consolidate memories of what we studied and learned that day. Rapid Eye Movement Sleep (REM Sleep), which happens in the last part of the night, appears to be associated with learning and memory. 

This all just reinforces the mantra that you should be getting eight hours of shut-eye if you want the full benefits of sleep. But those of us who are sleep deprived regularly and take care of patients know this full well and welcome days like today.

Residency doesn't appreciate, acknowledge or care about sleep. Imagine how efficient the system would run if academic medical institutions were filled with NON-sleep deprived people?

Behold, La Differance'

Ok, I admit it. I have a surgical personality and mid-set. It's what I enjoy most in my practice of medicine. I like the doing and the immediate gratification. I like the personalities better. So I have a bias. But I think I've figured out the difference between Surgery and Medicine in academia.

Surgeons do it.

Medicine thinks about it, pre-rounds on it, rounds long hours about it, provides a conference about it, makes a medical student research it and present it on those long rounds or at morning conference, runs the list later and discusses it....then consults surgery to do it. 


It doesn't catch you. You catch it!

Dear Healthcare Professional;

This is to inform you that during the period blah to blah, blah you may have been exposed to at least one case of active tuberculosis. A case that you were [closely and intimately, crawling all inside his orifices and fluids] has been recently been diagnosed by the country health department and may have not been showing clinical signs and symptoms when you were involved in his/her care. This information is provided to you as a Public Health Service and we would recommend contacting your primary care provider for immediate testing, evaluation and treatment if necessary. If you have any further questions please contact this office immediately at the above number and refer to case #blahblahblah. Thanks very much for the work you do.

[Love] Sincerely,
[Your director of county health department extraordinaire]

LOVELY! How unique to my profession to advised of exposure to the little elongated yellow beast. Let's review. Mycobacterium tuberculosis is a nonmotile (meaning they do not move) rod-shaped bacteria. The common site of infection is the lungs because the bacteria are obligate aerobes, meaning that they require oxygen. The cell wall of Mycobacterium tuberculosis is mostly lipid which contributes to difficulties in staining and dyeing the bacteria for identification. The bacterium is difficult to kill because it is resistant to antibiotics and other treatments. And it loves to dig large caverns of space from normal lung tissue (cavitary) and fill them with gobs and blobs of fluide, semi fluids, pus, sputum and other hairballs.

Lovely. So not only do I work unimaginable hours working for mostly children supervisors with little or know knowledge of adult education or supervision, but I also have been exposed to a bacteria with a passion for my lungs. Poetic.

I'm off today for the first day in over two weeks. I think I'll just focus on the things neglected (besides my health) and go to the gym, shop for food to fill my empty fridge and wash sheets. If I think too much about this bacteria crawling around in my lungs, I'm sure I'll quit and go back to my drive thru job at the donut place. But then I could be exposed to flour or chocolate sprinkle inhalation. Lovely.

Unpredictable variability

There is nothing more predictable than variability in learning in medicine. Largely perpetrated by the type of patient rolling through the door, the learning is based on the patients, their presentations and how those patients are utilized in learning. That variability is expected, understood and often the excitement that is learning in medicine.

But then there is the variability that is nothing but stress, created by the leaders of learning. That stress is caused by unpredictable, variable and ghostly expectations. The ones that largely live n the minds of those guiding the learning. Would it be so damaging to create success paths instead of failure paths at all?

Predictable variability is a God-send.
Unpredictable variability is a night mare

Friday, September 28, 2012

Stand there, just don't do something!

That's the funniest exchange I've heard in a few days. They are so common in this bizarre world.

Anesthesiologist to me: Just don't stand there, do something.
10 seconds later
Nurse anesthetist to me: Don't help. Too many hands are just confusing.

I couldn't do anything at that point due to laughter. I think the anesthesiologist needs more coffee.

Pervasive Burnout

Just read "Pervasive Doctor Burnout" Great to know as I start this wonderful field. . 

I don't know about the research. It's a little suspect. 

I just left a drinking party with a whole room 

full of interns and residents in medicine and surgery. 

They all were handing their liquor in excess just fine. Happy about nothing mostly.

Monday, September 24, 2012

I'm so sad it's over, it's over

Rotation's almost over, almost over! And I can't believe it's over, it's over. But I'm so glad it's over, it's over. Sad good byes to everyone tomorrow....but not THAT sad!

Sunday, September 23, 2012

Wrong stories

Sometimes, when we hear, or tell stories...we just get it all wrong. Even worse? When we try to interpret and provide opinion on wrong stories.

Too Easy

I won't do it. 
It would be too easy to blast someone who asks for constructive criticism who says she's an expert. She did. Told me she knew everything about the topic we were talking about then asked for my feedback. Really? How open. 
The world of medicine is filled with such types. People who will tell you they are open to critique and really constructive critique, who play the game and do the lip service. It's so fake. It's so unhelpful.
I know I don't know anything, so what would I have to contribute anyway? 
What a sham. A rock, I'd be. I'd rather kiss a bloody stone, upside down.

Friday, September 21, 2012

Good morning Siri!

I dream of the perfect Electronic Health Record (EHR). I walk into the physician workroom, sit in front of the computer, enter my user name and password and up pops EHRick....

Good morning EHRick.
Good morning doctor. What can I help you with today?

Were there any admissions overnight EHRick?
Let me check. Yes, there were 3.

List of diagnosis please.
DKA, post stroke dizziness, and intractable nausea and vomiting.

Any missing documentation?
Yes doctor. Admission orders for #3.

Thanks EHRick. Koolphrase, general admission order set.
Done. He's allergic to PCN, percocet, Norco & asking for morphine.

Thank you EHRick. Please print a census complete with map. And take me past the Starbucks stand please. And report patient #3 to the state narcotic database.
Checking.....I have it. I'll print your map now doctor. Landscape print? Reported.
Landscape print will be fine EHRick. Thanks.

Any calls EHRick?
Yes, your accountant, your lawyer, and your therapist. I've scheduled appointments.

Thanks EHRick. Have a nice day.
You too doctor; Don't forget your list.

And doctor, I've ordered flowers for your Mom's birthday.


Wish I had a dollar for every time I've heard someone in medicine say "I've sold myself to the devil". It's less an emotion than it is a commentary on the system I think. But it's clearly borne of doing too much with too little for too many.

Tuesday, September 18, 2012

Out of the mouths of babes

I love it.

Patient said, "you might want to tell your boss [attending] he/she has the bedside manner of a circus clown, goofy smile and all"

Monday, September 17, 2012


It's an ominous sign and finding in medicine. A patient needs to have clots stopped so the clots don't do damage to end organs...stroke in the brain, infarction in the heart, thrombosis to any other organ that needs a blood you give heparin, a medicine used to stop the blood from clotting.

And then it happens...a rapid fall in the number of platelets with more clotting than even before you gave the heparin. The patient has HIT...Heparin Induced Thrombocyto(platelets)-penia(too few). The heparin has bound with PF4, joined an IgG, formed a complex and then attacks the platelet...marking it for destruction in the spleen or activating it to clot...what you don't want in the first place.

It's essentially an allergic reaction to the heparin and a good thing to know before you go into the hospital as a patient. It's not a good idea to get HIT!

Saturday, September 15, 2012

Oh no!

Ugh, I have to go back to work tomorrow.
I guess things could be much worse, like world destruction, rocks hurling toward me from space, dogs living with cats, mass confusion, madness, mayhem...
Maybe not.

The Most Important

I pass this guy almost every day. He's the guys who rides the motorized floor sweeper, mopper thing all day long. With the hundreds of feet, maybe miles, of corridor in our hospital, it seems to be the most efficient way to clean it daily. And he does, with great regularity, attention and dedication. Day in, day out.

He is a reminder to me every day that even though the business of the hospital is to treat patients, there are many people here who let us do what we do by what they do. Sure the docs, nurses and people in patient are doing the billable work of the hospital, but without the "Sweeper Dudes" and such, we couldn't do what we do. They really create the environment to do this work. They insure the leaks are patched, the air is conditioned, the walls are painted, the spills are managed, the pumps pump, the dispensers dispense and the floors are clean. And for a hospital this size, it's no small task.

I say hi to the Sweeper dude every day. I never forget that he and his comrades create the space, the environment, the world, for me to do what I do.


My air conditioner broke the other day. Turned it on and it blew nothing but hot air. I'm no air conditioning expert; I'm a user. I didn't know what was wrong or how to fix it. All I knew, it was broke and I could feel the hot air blowing on me. So is my experience with medicine leadership.

Ideally leaders are forced into position. They take on the role of lead reluctantly with little regard for title or power. They live the idea of bottom up leadership and support, like a bottom foundation, by support, gentle correction and stewardship over those above them...under their lead.

Few have that insight. Even fewer can pull it off.
If force is needed to lead others, it's not leading.

And that is perhaps why medicine is in the condition it is. Too many would be leaders who really can't lead. They create small collections of power and force in groups, departments, programs, and such without really contributing anything to the team at large. Too many egos. Too much struggle for power and control over money, patients, resources, time, rooms, name it. Little effort to truly lead by example and forge new understanding and territory for the greater good, in service.

I'm so dismayed by this business and the people running it. I'm no expert, and not capable myself of doing what I see needs to be done. I don't have the calling, the brains or the power.

But you don't have to be an expert to see this isn't working. It's just blowing hot air.

So deep

The theater of rounds in academic practice is so silly. It has little to do with reality of the practice of medicine and creates nothing but useless competition, unnecessary banter, misplaced efforts and rounds that last for too many hours.

Chasing the little energizer bunny leader is certainly good exercise. So try to keep up, try not to get side tracked by anything as foolish as talking to the patient, coordinating care with other professionals or to answer a question for the family. You might not want to miss the inspirational and deep commentary of the chief or leader. Everything you say is so, so profound.

"This will be on boards". No it won't and if it was, you'd be in violation of the code of conduct for the boards by telling us that. Besides, I'm not taking your boards anyway.

Dr. Stead, Duke, said that academic medicine had too few who actually could teach. Even fewer who could lead. I really thought he was kidding.

Tuesday, September 11, 2012

Could be worse

As bad as yesterday sucked, could be way worse. Remembering 9-11.

Monday, September 10, 2012

I suck!

That sucking sound you heard today was probably me. Or maybe it was just "this", as in "this sucks". But I can't imagine a worse day in medical education or care.

After rounds I found myself alone. Everyone else bolted to their respective roles and responsibilities, leaving me to cover the entire service myself. Not a single word of goodbye, support, guidance or anything remotely looking like team work.

Now that wouldn't be so bad if the service wasn't filled with sick folks, if we weren't on call for new patients, if I didn't have to discharge several patients or if I was even remotely interested in this type of medicine. And more important, I'm not even close to being an expert at this. Frankly, I suck at it.

But there I was. Left alone to fend for myself, with little knowledge of the system, the rules that make little sense, the back up that appears to change like the wind or the practice of this type of medicine. On a good day, there would be 5 total folks doing this work. And there I was. Alone.

I've finally finished the day's work after working for 18 hours. I have to be back at 6 AM, less than 6.5 hours from now. The bed beckons. Retirement screams!

Friday, September 7, 2012

Fever, chills, night sweats!

A winner... a patient with a 107 fever. That's a record for me. Actually beats the patient with the over 1000 sugar in "most likely to be unconscious having a seizure" award.

Sun geek...the new sexy

Saturday, September 1, 2012

Tragic Loss in Twitterland

I'm sort of numb to this sort of stuff. Too many people have died around me on or around cars and motorcycles. Yet a couple of weeks ago, on a winding road in California, a man from the UK on a rented motorbike was killed. And I felt a great loss.

I'd never actually met Ian, but I've been following him, literally, for several years on Twitter. He and his friends posted some very witty observations about life and social media. I stumbled upon he and his friend Corrine one day, searching for motorcycle tweets. They were enthusiasts, like me. They were living life and chatting to each other and friends about upcoming plans for a great adventure on a bike to Northern Africa. I was hooked.

I began to take great interest in their lives and how they figured out work, school, moving, dissertations, social media, politics, cigars, drinking beer and fine liquor, foods, motorcycles and a host of other topics...just living. I felt a bit like a voyeur when I'd catch @Peregr1n chatting with @PolarIceQueen. I felt every ache she felt when they wrecked their bike in Africa and broke her wrist.

And I suspect that my attraction and fascination is not unusual on Twitter for others as they view other people's lives on Twitter or other social media.But what made this unique, I think, was the candor and unique perspective Ian had for social media as a user, and as an IT professional in Europe. His wit, intelligence, humor and sophisticated perspective oozed from the tweets and made me chuckle regularly. I particularly appreciated the love and real friendship between him and his friend Corinne, something many never achieve and only yearn for.

I've been so, so busy, that I've not been on social media much. It's been a challenge to get to the grocery store let alone keep up with Twitter. But I had a break to do just that and check in with Ian and Corinne. And that's where I found out about Ian's death, and Corinne's loss and devastation. The last thing he wrote about was trying to figure out the gas and gauge operation of his rented bike. 2 weeks ago, Ian (@peregr1n) wrote:

"Oh if someone could tell me how to view the fuel gauge on the Ducati Monster 696's digital display I'd be very grateful!"

He must have been hit by that pick up truck right after that tweet. I hope it wasn't a stupid tweet distraction that got him killed.

I read later where she had to fly to California to "bring him home". I can't imagine the loss Corinne feels, but actually felt a little part of that myself. And the irony is not lost on me that I was just looking at Ducati motorcycles in the cycle trader the other day, thinking about it. But worst will be the loss to his friends, colleagues, and Corinne. I know nothing can remove the pain and shock of this, but I hope that there comes comfort and great knowing how Ian affected others. RIP @Peregr1n , RIP. I for one, will miss you.