Safety deposit box

Vault I by chesh2000pro

Now that I have a J-O-B, and I am officially an adult, I decided to get a safety deposit box to store all those invaluables, like some jewelry and papers.

I went to the bank and signed up for a box. The bank teller and I went into the vault, and we both put our keys into the locks, and I pulled out the box. The teller escorted me to a private room, and I played with the contents, putting this in and taking this out.

And driving away from the bank, I thought it was so funny how much trouble it was: the vault, the locks, the security, the private room. We spend so much time and trouble to guard and protect things. Everything in my safety deposit box, it can't be worth more than a few thousand dollars.

Yet we are so utterly careless with our emotions. We hurt each other so recklessly without a passing thought. We guard things that can be replaced, but we don't protect the things that really matter.

And sometimes, I can see why, because if we could lock our hearts in little steel boxes, then how could we ever give our hearts to each other, share our joys and sorrows? I'm learning, slowly, that I have long locked away my heart, and I have kept it safe, but how can I share my heart if it's hidden away?

Delightfully tacky

behind the scenes at hooters by o0karen0o

I know this probably won't endear me to the female readers, but I love Hooters. I would say that I really like the food, but I can hear the outcry already. The food is very good though, and it's hard to get spicy hot American food, but their wings and sauce are HOT.

But the best part about Hooters is that it revels in its tackiness. This is what drew me to Hooters on a beautiful day with a friend of mine, Macintosh. Mac had never been to Hooters before, so we had to go. Our server girl was nice. It's just a fun place to eat.

I actually go by myself sometimes because the Hooters near me has an outdoor patio where few people sit (because indoors are where all the girls are), so if I want to eat outside, there's always a table. It helps that I actually like the food.

My favorite Hooters memory was in med school. Me and Chocolate Thunder went on one of our man dates. We went to the local museum and soaked up the arts. Afterwards, we had to counterbalance all that culture, so we stopped at Hooters for dinner! The waitress thought that was hilarious. I mean, how many people at Hooters just spent a day at the museum?

The confusing thing to me was the table next to us was some guy with his 4 yr old girl and his 60's mother. Overhearing their conversation, he took his mother to Hooters for her birthday. WTF? That just doesn't make much sense. I mean, who takes his mother AND his daughter to Hooters?

If you've never been, I recommend it, because it's one of those places where you feel like they enjoy your presence, and sometimes when you live a solitary life, it's very nice to have someone talk to you for a minute and seem interested. ... I must really be starved for meaningful human contact.

loser

loser by ifinding

I was surfing around on CT's blog and decided to take the web quiz. While I was taking it, I ran into this question, and I just had to laugh long and hard. I am the living embodiment of answer B.

I think that all of my annoying, stupid crush posts are ample proof of that...

Are you smarter than a fifth grader?

fifthgrade by JohnnyCashsAshes

I watched this new game show, and I experienced a mix of horror / shock / mortification at the stupidity of these people. I mean, how can you CHEAT off of a fifth grader? But really, Americans are pretty stupid. Whenever we talk to patients, the rule of thumb is that we need to speak at a fifth grade level, to ensure that we are understood.

That doesn't sound too bad, but you probably haven't spent any time with fifth graders recently. Keep in mind, these kids are the target audience of shows like Power Rangers. It takes active effort to keep to that kind of vocabulary.

My personal rules are that you shouldn't use any word longer than 3 syllables, and you should use language to talk to families than is similar to talking to children. Now, you shouldn't treat them like children. It's just that your language has to be comprehensible.

I had a patient in the ICU, and the cardiologist spent time with the patient's DPOA and afterwards, I talked to the DPOA as well.

Cardiologist: Your brother had two lethal arrhythmic events, likely from acute MI. We've coded him twice now, and we did stenting on the LAD. Right now, he's on two pressors and he's hypotensive. I think that you should think about making him DNR.

me (after the cardiologist left): So, did you get any of that? [DPOA shakes head no]
Alright, your brother had a heart attack, [pause while she soaks it in] and his heart rhythm became so messed up from the heart attack that his heart stopped pumping blood two different times. We gave him CPR and shocked him, and the heart doctors opened up one of his arteries.
His heart is beating now, but at this point, we have to give him two emergency drugs to keep his blood flowing. Does all this make sense? [DPOA nods yes]
If his heart stops again, I'm not sure that we'd be doing him any favors by doing CPR or shocking him. We're already doing a lot of last resort types of things. You should think about what he would have wanted.

Seems like I said almost twice as much as the cardiologist, but to his credit, he did take it a step in the right direction. After all, this is how I signed this patient out to the on call resident: 58 male s/p v.fib x2, now s/p LAD stent. Maxed on dopamine and levo. Full code for now.

Visions of the future

Zoltar's Hands by Roadsidepictures

The dumbest questions sometimes are the most obvious ones. When I was interviewing for a job after residency, I interviewed with a few private practice groups. They were a mix of very, very eager to mildly indifferent. Their questions mainly centered on the most obvious issues: will you stay with us?

They got to the point in a multitude of ways. One interviewer wanted to know if I had family in the area, or what I thought of their city, or whether I liked their local sports team.

The dumbest question I got though was a common residency interview question: "Where do you see yourself in five years?" Now, this seems like a good question, right? But really, when you're interviewing for private practice jobs, there's no such thing as advancement, just partnership. If they hired me on, I'd be doing the same thing in five years, but hopefully as a partner. It'd be like asking retirees where they see themselves in five years: hopefully not dead, hopefully still retired.

My reply? "Umm... working for you?" I didn't know what he wanted me to say. Did he want me to say, "Well, I thought I might meet the girl of my dreams while wandering the clean streets of your fair city, and we'd fall in love, attend performances by the local symphony orchestra, and have a child who will one day attend the local university."

Maybe he wanted a more truthful answer: "I hope to be the first person to have full season ticket packages in baseball, football, and hockey all at the same time." Or perhaps something better? "I see myself driving a BMW and eating fruit off the breasts of a $10,000 hooker." I just don't see the point to his question.

I think the nice thing about private practice interviews is that people can talk straight, no bullshit. For example, one place I interviewed at handled the question like so: "Alright, you seem like a good guy. If we take you on, are you gonna stay here, or are you gonna leave after 2 years?" If only all intereviewers could be this clear.

Saving grace

Talking about... by Lionoche

Sometimes, call is nice. Sometimes, call is tough. Sometimes, call is just motherfucking awful. And I've had my fair share of nice calls, but in my 3rd year now, my calls have been absolutely miserable.

I have not been dealing well with the stress. It's tough work, and it's a lot of weight to carry. And the only thing that keeps me going is coffee. I need coffee to survive these calls, because after 24 hours of living hell, I can't make it another 6 hours without some help, and the cafeteria doesn't carry amphetamines.

And then, I had my worst call ever. I was covering the ICU, and capped out with really sick patients. I had in one call: 2 family meetings, 3 patients terminally weaned off the ventilator, 4 or 5 central lines, a couple codes... It was that nightmare call you pray never happens to you. It was the Moby Dick of calls. I had one code while I was intubating another patient. The only worse thing I can imagine is simultaneous codes (I've had that happen to me too, but not this time).

And when the worst of it was over, all I wanted was a cup of nice, decent coffee. So I went to the cafeteria at 5AM and poured myself some coffee. It was burnt, nasty, and tasted miserable. It threw me over the edge. I was yelling at staff, critical of my interns, and my signout to the on-call senior was: "You take care of them. I'm fucking done with this."

Everyone knows me, though, and knew that I had gone through hell that night. But we cut each other a lot of slack post-call, because we all know that calls can suck, and sometimes suck very hard. And sometimes without that little saving grace, it's easy to be crushed.

I apologized to one nurse the next day, as I had yelled at her, and implied that she had no idea what she was doing. Her reply: "Oh, don't worry about that. If I had the night you did, I'd be running around shooting people!"

Church Barbie

... by strochka

Every week, my church has a lot of different mass times, but I go to the same mass every week because of one girl. She is a girl I casually refer to as church Barbie. I call her this because she is very blond, very pretty, very curvy, and very much an object in my eyes rather than a person.

After all, I don't know her. I have never had a conversation with her. I have in fact heard her say a total of 6 words, none of which were her name. She is just a pretty girl sitting in the next pew. For all I know, she is rude or mean or *shudder* a typical girl in her early 20's. I don't know.

I like to tell myself that she must be one of these shallow girls whom I've met so many times. Nothing is less attractive than the sense of entitlement that comes with being beautiful. I think back to high school sometimes to one girl in my class. She was gorgeous. I mean, wow, absolutely beautiful, but she was the worst person I had ever met. She was bitter and shallow and hollow. Interacting with her was sheer torture. It's like eating a chocolate truffle only to discover that it was full of vinegar and mustard.

So, I like to enjoy her from afar. That sounds far creepier than I mean it. What I mean to say is that I like to enjoy the beauty in the world, and I try not to question it. I try not to find the flaws and blemishes and cracks.

I used to go birding (aka bird watching) a lot when I was younger, and stargazing. I still go stargazing every now and then. I love to go to museums and wander through room after room of beautiful things that I cannot touch. I have sat for an hour in front of a painting of El Greco, soaking in the beauty of it. I walk through the woods and photograph things, trying to capture of beauty of it. I enjoy seeing beauty in the world.

Still, I know that there is another whole plane (as in plane of existence, not 747 plane) upon which beauty exists. I am just seeing the shadows on the walls of the cave, and am somehow content with that [blatant Plato's Republic reference]. "A bird in the hand is worth two in the bush" is often credited as an aphorism but it simply isn't true. A bird in hand is worth far more than two in the bush, or ten, or two hundred, or even a million.

Because a bird through the binoculars is beautiful and wonderful, but it is not mine. I can only enjoy it from afar, like the Mona Lisa behind bulletproof glass. And that is the relationship I have with church Barbie.

I love surgeons

Surgery, Italy by marmont59

Surgeons are great folks. I was talking to some of the surgeons today about a patient, and they didn't know the patient's name. It was such a classic surgeon moment.

The thing I love about surgeons is that they are so very different from me. However you want to cut it up, my ability to do my job is entirely dependent on my ability to get reliable information from the patient. I need to establish rapport. I need to ask the right questions. I need to review systems. I need to advocate. I know my patients quite well.

Surgeons however, some of them at least, go out of their way not to know their patients. Of course they know the medical issues. They know the past history and the physical findings and the lab results. Sure. But I'm the one wasting my time talking to Mr H about his service in WW2.

I think that the reason for this is that it takes a certain level of detachment to be able to cut someone open and play with their innards. Surgeons have to distance themselves quite far from the people they cut on. It would be too much to see Mrs M, mother of 3, grandmother to 10, baker of the best pies of all the ladies in the local Legion auxiliary, as a scared and fragile human being. It is much more sane to view her as 20cm of necrotic colon.

I remember one of the surgery residents I worked with as a medical student. We took out half of this lady's colon because of obstructing mass. When we opened her up, we found diffuse metastasis all over the abdomen. We did a colostomy and that was that. I asked him several days later if she had a shot at survival. "I'm sure she'll do fine. We did our part."

Despite what you may think about surgeons, it seems to me to be quite an optimistic specialty. While I talk about CHF and renal failure and lethal arrhythmias, they cut to cure. And although I may disagree a lot of times, it's nice to have someone who thinks he can actually do something to make a difference.

The awkward turtle

AKWARD TURTLE! by abraver

I am officially old. I saw some college kids sitting around and one of them was doing this weird hand gesture. I was completely lost. I didn't think much of it until I found out about the awkward turtle.

For those of you who are also old, the awkward turtle is a hand gesture designed for the purposes of expressing the awkwardness of a situation. Example: your college professor is hitting on your friend. Awkward. And so you may display the awkwardness of the situation through the awkward turtle. It should be done inconspicuously, so that the instigator of awkwardness is not made aware. Were those college kids making the awkward turtle because I was staring at them? Doh.

The reason why I say that this means that I am old is that I distinctly remember being of the age when things like this abounded. It was stuff like "All your base are belong to us," dressing in flannel and torn jeans, and knowing that our parents had completely lost the ability to understand us. We communicated in some bizarre language that made no sense to the grown up world.

And it's entirely because of insomnia that I knew about Aqua Teen Hunger Force. Who knows what else I'm missing? I mean, I made a MySpace page just to say that I have a MySpace page, only to find out that MySpace is so last year, and that Facebook is the new MySpace. Wasn't MySpace the new Friendster? And wasn't Friendser the new Classmates.com?

It's official. The terrorists have won.

Flipping Boston the Digital Bird! by LotusMonger

So, in a bout of insomnia, I was watching Cartoon Network, getting my fix of Futurama, and I see this odd bump (you know what I'm talking about if you've ever watched [adult swim]). It's apologizing for something in Boston? So, time for a websearch!

Turns out that all I needed to do was change the channel to Fox News to find out that apparently, these guys putting up Lite Brites around Boston are master criminals and jeopardizing national security. Let me repeat myself. According to the media, LITE BRITES ARE JEOPARDIZING NATIONAL SECURITY. I cannot believe that the city of Boston was paralyzed by LED's of Ignignokt, whom if you asked any random teenager on the street, would probably be able to identify. It would be like shutting down the subway system because of Towelie dolls found on the trains.

Everything we have done in this country for the past few years has been motivated by this ridiculous fear, paralyzing fear, that someone is out to get us. And we are so afraid that we fail to use things like common sense. We do things like piss off every single country in the world, and somehow remain convinced that we are right.

I have made fun of the phrase "...then the terrorists have already won" and how people used it all the time, and so ludicrously. But it's hard not to feel like we're a little less innocent today. Because this wasn't a subway plot. This wasn't canisters of anthrax. This wasn't a cache of guns and C4 found in the local dam. This was Lite Brites of a cartoon character flipping the bird.

An interesting note though, ten cities had these LED signs, and only Boston went into a hissy fit about them. So maybe it's just Boston that's gone to hell.

Graduation!

Freedom! by Noeluap

One of my patients said something funny in the clinic. She has survived breast cancer. Five years ago, she had her left breast cut off, lymph nodes taken out, chemotherapy done, and she lived with the sword of Damocles over her head for five long years. When she came to see me, a glow was about her. She could barely contain her excitement that it was time for me to order a mammogram. I had never ordered a mammogram for her. Her oncologist had been dealing with mammograms this whole time.

She had graduated oncology, as if oncology was some sort of perverse high school where the hazing of freshmen involves surgery and chemo, and graduation is accomplished simply by being alive after five years. The dropout rate is so atrocious that if it truly was a school, it would've been shut down long ago.

Now it was time for her to be followed by her PCP once again for the routines of life. She had spent five years thinking that the cancer would come back, that her days were numbered. She didn't think that it would be five years. She did not think she would graduate. Now, her joie de vivre was renewed.

"Dr. IFinding, when was my last cholesterol level? Do I need one? Because I'll be damned if I'm going to survive breast cancer just to die from a heart attack." I love my patients so much sometimes.

By the way, I've been putting up flickr pictures to accompany my posts. If you want me to stop, let me know. I think the pics add a little character to the posts, but I can certainly understand if you think they're a detraction.

Positive muffin sign

Muffins by beta karel

In medical school, our cafeteria was terrible, but the patients had it much worse than us. Patient food was miserable, bland nastiness. However, there was one tidbit of salvation: the breakfast muffin. Every breakfast was powdered eggs and something resembling sausage, terrible coffee, and what I assume was oatmeal. But the joy of every morning was the blueberry muffin that came with breakfast. It was moist with a little crunch to the crust. The blueberries were rich in flavor.

And I slowly came to realize that one could determine the acuity of illness of any given patient based on the muffin. If it was entirely consumed, the patient was improving. If it was half eaten, then the patient might be stable, or may be declining. If the muffin was not eaten at all, then the patient was definitely declining. Even the dysphagic patients went to town on the muffins, knowing that it was pretty much the only thing worth aspirating.

The muffin was such a reliable estimation of patient wellbeing that I would actually ask patients about why they hadn't eaten their muffin. And in my mind, as we rounded on patients, I would tally up the muffins, and chuckle. My attending would say, "I think he's doing better!" but the patient didn't eat the muffin!

In an alternate universe

the gospel reading by danielkedinger

Going over this blog, I am surprised that I have not had any posts regarding probably the biggest choice in my life which I made sometime in high school, and that was simply: doctor or priest?

For those of you who may not know, in high school in the midst of my morose, teenage existence, I very seriously contemplated the Roman Catholic priesthood. In the end, I couldn't do it. I thought and thought and thought, but I decided against the priesthood. I just couldn't reconcile being alone for the rest of my life, without companionship or love or intimacy. It was too much of a void.

But fifteen years later, I have had all of two relationships, a number of dates that I can actually count, a complete absence of physical intimacy, and without a date in the last two years somewhat by choice. Now I question my teenage decision. I seriously wonder about such a strange choice, made with the presumption that I would probably be married by now, possibly with children. The plan was never that I would still be single.

I made that choice with the hope of love. I made it with the dream of finding another person to complement me, to share my life. I made that choice based on potentials and possibilities, and not about what I had or who I was. It was a decision of what was outside of me, outside of my control, and not anything to do with what was within me, except the intense desire to be loved.

And still, I have this intense, burning desire to be loved. It's not as much to love; it isn't reciprocal. I want to be loved, to be welcomed, to be held tightly. And honestly, I don't want to love someone as much. Still, I would love to love, to give my heart to someone, but I the idea that I am loved, that I am necessary, this is what has motivated my life.

My decisions and actions since this life changing, teenage choice, they have all boiled down to me being needed. My patients, I treat them with such compassion and earnestness because I seek their approval. I need them to see me as necessary, and to accept me. I am at heart a very selfish person. It is just that my selfishness is manifested by such altruism. It is like what Emerson said: "It is one of the most beautiful compensations of this life that no man can sincerely try to help another without helping himself."

Today, I find myself in such a quandary, because I find that decision in front of me again, and I'm not sure if I made the right choice. I don't know that I would choose the same path, knowing what I know now. It would be nice if I could look into an alternate universe and see what that other life would be like. Maybe I would find it to be the better choice, but I don't know that there is such a thing as better.

Part of what makes this choice not quite as disturbing these days was that when I was thinking about it more than a decade ago, it was with the knowledge that both choices were good ones, that I could live with either. I could never look upon a life as a doctor and say that it was a worthless endeavor. I couldn't see being a priest as a waste of time. It was a choice between two goods, not two evils.

Really, it's not about which choice was better, but which was right for me, because I didn't make that choice based on intrinsics but on what was extrinsic. If I think about who I am (or rather who I was) I'm not sure that I chose right. I'm still not sure, on the cusp of being an attending physician, if medicine was right for me.

I know that I have done good work. I have held the hands of the dying. I have comforted the sick. I have healed when I could, and done my best. I have without a doubt in my mind done good. If the scales of my life were to balance today, I would tip in the right direction.

I remember one of my patients was dying from florid sepsis, and the patient's sister refused to let the patient's boyfriend visit. She barred him from the ICU room. I sat her down in the nursing station and told her, "Your sister is not long for this earth. I have done everything I can do with medicine. There is no other drug I can give or procedure I can do. You have the exceptional duty to carry out her wishes, so please, whatever you may think of this man, please think of what your sister would want." She relented and let him see her as we turned off the levophed and dopamine. They wept and hugged, and she thanked me, she THANKED me, the man who let her sister die. Because love always beats hate.

And I had one patient with severe mental retardation without any family, and I held her hand and sang to her happy birthday, as the nurses turned off the vent and let her expire from sepsis. There was no one there to celebrate that day but me and the nurses. And after exactly 64 years on this earth, I stopped her life and closed her eyes.

There is not a doubt in my mind when I meet my maker that my soul is defensible, that I have done good with my life, and that was never the question. Because everyone is capable of doing good. The question is what was right for me. Because it's not like being a man of God is not without its own benevolence.

I remember I was in the hospital one day, and I met my priest there, standing over the body of one of my patients, a very wonderful lady who blew a vessel in her brain and was now brain dead. My priest thanked me for helping the patient's family. I pronounced the patient dead and left. I have to admit though that I was envious of that priest, that his job was just beginning and mine was done. And I wonder if maybe I made the right choice.

Better living through chemistry

Pills by kodama (on the road)

Last week, I caught an upper respiratory infection, and thankfully, the worst of it was over the weekend, but I still had lingering symptoms for a few days while at work. It was for this reason that I initiated the Better Living Through Chemistry campaign of Winter 2006/2007. Normally, I don't like taking medications, and I will avoid them until it is entirely unavoidable. But I can't justify sneezing and dripping all over patients.

I started with ibuprofen 400mg bid while at work. On top of this, I used triproline/pseudoephedrine 2.5/60mg [trade name Actifed] for the first few days q6 hours while at work, giving myself a break while at home. However, my supply of Actifed ran out, and going to the store, I discovered that all the pseudoephedrine is now kept behind the counter. So, I switched to chlorpheniramine/phenylephrine 4/10mg again q6 hours while at work.

it took about 9 days for symptoms to resolve completely, and I feel fine now, but it's always interesting to go to the OTC aisle. I saw several people wandering the decongestants, looking at one, then pondering another. For all of you reading this, they're all the same! Choosing a decongestant has more to do with your own body's reaction to a specific chemical than anything the drug company can tote.

I was however alarmed to find out that phenylephrine is in my OTC med, the vasopressor that I run into people as a last resort, mainly because it is such a potent peripheral vasoconstrictor that I have induced limb ischemia.

Thank you, Target!

target by rkobe

I have long decried the completely esoteric world of prescriptions. The written scripts themselves are in some bizarre language. Sig? bid? Disp? How nuts. But even worse than this is the crime that pharmacies have perpetrated upon their customers. At least when I write a script, it goes to a pharmacist who has a decent chance of deciphering the thing. Most prescription bottles are written out and dispensed in just as confusing a manner as the original slip.

I am a medical doctor for goodness sake. I spent a literal 30 minutes trying to decide if "Take twice daily" was two tabs daily or bid. I ended up looking it up in ePocrates and taking it how I thought I should take it. But seriously, even I have trouble.

So, imagine my surprise when I saw the new Target pharmacy bottles. The name of the medication is written in bold on the top. The instructions are in large print and clear. There is a color-coded band for each family member. The bottles have flat surfaces so you don't have to twist and turn the bottle to read the instructions.

The bottles were designed by Deborah Adler as part of a thesis project for the School of Visual Arts, and was quickly snapped up and patented by Target. She was inspired to do this by her grandmother, who accidentally took another family member's medications.

I tell all my patients to physically bring in their medications to visits, so when one of my patients brought these in, I was stunned. They were clear, intelligible, and my patient, who previously could only identify pills by, "oh, it's the little blue one" could now tell me which one was her Plavix and which was her Lasix.

Normally, I could give a rat's ass about where my patients fill their meds. I don't think that there is any difference from one pharmacy to the next, except who offers a deal or some such. However, I am now encouraging Target for my patients who have a hard time with meds, because I think this is the greatest innovation in prescription medication since the advent of child safety bottles.

The future of medicine

Bobby Labonte
uploaded by Mulsanne

Whenever the pharmaceutical reps come through, they throw all kinds of stuff at us: pens, paper, post-it's, stethoscope tags, pen lights, and more stuff always coming through. Doctors are given a lot of items.

And I don't take any of this stuff for the most part, because this picture encapsulates my fear. I think that this is the direction that physicians are moving, and eventually we'll be wearing white coats that will look remarkably like this.

So I don't take any pharmaceutical stuff like this. I'm not divested from big pharma. I still take the occasional free meal, and I go to a few dinners every now and then, but I don't accept any advertising material, because I don't want my future to look like this.