What cow?

Had myself a lovely evening tonight. I was in the Family Practice clinic this afternoon and it went quite well. My staff (the doctor in charge is called "staff") let me go see patients on my own and was very good about letting me present my own differential diagnosis and treatment options. (We get more autonomy this year than we did as third-year students.) And I was out of there by 5:30 (going home early by sub-I standards).

So I was riding high when I left and decided to go find a Vietnamese restaurant that my resident had recommended. Find it I did, ate there I did, and enjoyed it very much I did. In fact, it was the best Vietnamese food I've had in Iowa. Charmingly, the restaurant is called Da Kao, and their fliers feature a picture of a smiling cow--a bilingual visual pun! Well, I'm easily amused. Anyway, if you're ever in Sioux City check it out at 800 W 7th Street. It looks like this:



(Picture shamelessly plundered from here.)

After dinner I took the scenic route home through Grandview Park, which lives up to its name. A lovely summer evening with a view and Django Reinhardt's "Bricktop" playing on the radio. Sioux City might be a little rough around the edges here and there, but I'm growing attached to the place.

Things to do in Sioux City when you're not on call

Today was a day off, so I spent today being a tourist. (Except that I brought an OB/Gyn textbook along for a little light reading. It occurs to me that I'll probably be in the hot seat for a delivery sometime soon, and since I haven't done that for about eight months I figured it might behoove me to review the instruction manual.)

I started off at the Lewis & Clark Interpretive Center. They had a nice video showing L&C's encounter with the Blackfeet from both perspectives, but the animatronic Lewis & Clark kind of freaked me out. It turns out that Charles Floyd, the only member of L&C's expedition to die on the journey, expired nearby and was buried on a bluff overlooking the Missouri River. I was delighted to be offered the opportunity by one of the exhibits to retrospectively diagnose Sgt. Floyd's illness. L&C diagnosed "Biliose Chorlick," but it is now thought to have been a ruptured appendix. (I concur.)

Next I stopped by the M.V. Sergeant Floyd, a river steamer that's been put ashore on the riverfront and converted into a museum. (One of many landmarks in the vicinity named after the good sergeant.) Nearby is the Flight 232 memorial. (In 1989 United Flight 232, a DC-10, crashed trying to make an emergency landing at the Sioux City airport, killing 111 out of 296 people on board. It's a gripping story, well worth reading.) Also nearby is the Anderson Dance Pavilion, an open air venue on the river. Visiting these sites I got the message that Sioux City is very serious about its flower gardens. Everywhere I go there are nicely-tended beds of very colorful flowers. Finally, a five-minute drive took me to the charming, Guggenheimy Sioux City Art Center. Spent an enjoyable hour or two there. (I have a thing for small museums, of which more later.)

From the riverfront I headed up into the hills. Specifically, up to the bluff to see the Sergeant Floyd Monument. It's a mini-Washington Monument that dominates the southern approach to Sioux City. It was built after the Missouri had eroded away the original site of Floyd's grave.

Heading upstream from the monument site, I found a vantage point on a high bluff directly overlooking the very easternmost tip of South Dakota, where the Big Sioux River flows into the Missouri. In fact, I was overlooking the triple border of South Dakota, Iowa, and Nebraska (although I couldn't actually stand on the triple point without wading into the river). On the drive back I even had a delightful wildlife encounter: two wild turkeys were crossing the gravel road with about eight young ones (chicks? turkettes?) in one direction, and then a deer came out from where the turkeys were going and crossed the road in the opposite direction.

A very nice day off. Now it's early to bed so I can be up for rounds at 6:00 tomorrow morning.

Priorities

Looming over all of my med school activities these days is the upcoming application to residency programs. And as with so many other applications, a big part of it is The Personal Statement. No big deal, no pressure--just give us a sense for who you really are as a person and as a medical student and explain exactly why you, rather than one of the 16,000 talented, accomplished other applicants we can choose from, should be granted an interview. Oh, and keep it to one page, please.

Not really anyone's favorite writing task. But today, in a triumph of self-discipline, I used some off-duty time to sequester myself in a little-used conference room, staked out a computer, and banged out a serviceable first draft. And rest assured that, being a medical student, I have a firm grasp of priorities. As I was finishing the fire alarm went off and I wasted no time following the correct procedure: I grabbed my backpack, got out my USB memory stick, and carefully backed up the most recent version. Just don't tell the firefighters we worked with a while ago....

An appeal for the South Korean hostages

Mr. Haythornthwaite, who has worked in Kabul before and will be returning later this summer, has a petition appeal on his blog regarding the South Korean hostage situation in Afghanistan.

The BBC has the latest. Mr. H. has a wonderful description of his reactions to his upcoming return to Kabul here.

Rx

Went to a great lecture today: tips for writing prescriptions. There can be quite an art to it, and it's something that is traditionally only learned by physicians the hard way, after they're already in practice. Believe it or not, this is the first time in over three years of medical school that I've gotten any formal instruction on the correct way to write a prescription (and I've already written quite a few, although they all have to be countersigned by somebody with a medical license, of course). Before this I, too, owed everything I knew about it to a few clinicians who were kind enough to show me the ropes while I was working in their clinics. Hundreds of hours spent learning enzyme pathways and pharmacokinetics, but so far one classroom hour spent on the actual document to get all of this biochemical firepower into the hands (and GI tracts and bloodstreams) of patients.

It's got me wondering whether anyone I knew (perhaps even readers of this humble blog?) have had issues with a prescription that interfered with optimal delivery of their medication.

Dept. of Conspiracy Theories

Confidential to Pynchon devotees: In between the hospitals where I'm working there's a tattoo parlor called Yoyodyne Propulsion Systems. Yeah, sure, a tattoo parlor. Right....

Gender Pharmacostereotyping

Yesterday in the ER I went to see a young man with abdominal pain, a big, tough, muscular guy who worked construction. The big, tough co-worker who brought him in was there, too. As part of my regular history-taking I asked him if he'd taken anything for the pain. He hesitated a second, then said "Midol."

Um, Midol?

"Yeah, my buddy's wife had some and said it worked for her, and I was hurting so bad I was willing to try anything."

Did it help?

"You know, I think it did."

Then last night I was momentarily caught off guard by a gentleman who was taking an old-school antibiotic that I have only ever seen or read about being used for UTIs in women. I like to think of myself as being pretty good about not making gender-based assumptions, but you just can't take anything for granted in this business.

First Impressions

Last night on my way to Sioux City I stopped for gas north of Council Bluffs. When I saw a woman in the store with her jeans tucked into her cowboy boots and wearing a plaid shirt, I was reminded that this part of Iowa has more of a western flavor than the rest of the state.

Although there aren't really wind farms nearby that I saw, there are many single wind turbines here and there. A cool trend: painting the town's name on the windmill pylon, rather than on the traditional water tower. Passed a rest stop with three horizontal windmill pylons loaded onto flatbed trucks. An impressive sight: each one is about three times the length of a semi.

There's a great love of searchlights around here. There was a set of car dealership/movie premiere spots rotating out in the country, looking very eerie in the hot, humid night haze. Sioux City itself has a rotating searchlight right on the riverfront, drawing attention to what I think is a riverboat casino. Saw other searchlight beams on the way in, too. Maybe they're worried about Zeppelin raids.

Finally got to the student apartment around midnight and stumbled inside in the dark. It's a charming 1960s walkup with well-preserved fixtures: tiled bathroom, glassed-in sun room (although far too hot to sit in during the summer heat, even at midnight), wall-mounted pink oven still bearing the proud label "Frigidaire: A Product of General Motors Corporation." Fell asleep to the "thwom, thwom, thwom" of central air, which is much appreciated in this weather. Unfortunately we're going to have a full house--looks like we'll be sharing rooms, and there may be five or six of us sharing a bathroom. Unngh... I'm too old to have a roommate. Well, what are ya gonna do?

Heading off to my first clinic in a few minutes. Still trying to figure out my computer access issues. More guerrilla posting later....

Sub-I in Sioux City

"Oh. Well, how delightfully rustic."
--Sue Warner, Sioux City Sue (1946)

Today I leave for a month-long sub-internship in Sioux City, Iowa.

The preceding sentence probably raises almost as many questions for you, dear reader, as it does for me. Where to begin? I've already spent quite a bit of time in other towns and cities for various clinical rotations (or "clerkships," as they're called in medical school lingo). They have included many of my best educational experiences in med school, but they can also be stressful: learning a new discipline in an unfamiliar hospital; staying in student quarters with varying degrees of maintenance upkeep and varying numbers of fellow students; and generally being away from the comforts and friendly faces of home.

But this is not just any clerkship. This is my Family Medicine Sub-Internship. For the next four weeks I will be performing most of the duties of an intern, or first-year resident. (Hence the unwieldy term "sub-internship." To me it sounds like a character from Star Trek: "Captain, receiving transmission from the Romulan Sub-Intern.") The Sub-I is a chance to kick the tires, experience soul-crushing on-call hours, and generally get a fourth-year med student's feet wet.

So wish me luck as I pack up my white coat, stethoscope, and pocket medical references--I drive there this afternoon. Look for Northwestern Iowa bloggery coming soon....

From the Grand Canyon to the mean streets

Commenter Tom B was my Grand Canyon guru. He taught me the basics of hiking and foot care when facing a mile-high climb with minimal water, and yes, that background came in very useful during Friday's Wilderness Medicine Adventure Race. Fortunately we never had to make use of trauma management skills on any of our hikes together. He sends a link to this Grand Canyon Hikers thread with his response. The poem at the top is uncredited, but Tom's inimitable style shines through. ("Advice given here is not guaranteed. / Before you go a hikin' and wind up birdfeed....")

Finally, I nearly had a chance to put all this training to use just last night. It was a beautiful evening and Lady M and I were eating dinner outside at a downtown restaurant when a guy went past on a motorcycle. Once he was down the street, out of sight, we heard "screech" and then "crash." Lady M looked at me and mouthed "go!" and I ran over to the scene. On the way there I was wondering "will I need to start CPR? splint a leg? needle a chest?" As it turned out, the dude was already walking his bike to the curb, having sustained only minor ego lacerations and pride contusions. But it was nice to feel that if there had been a serious situation I might have been able to help. Eager to help, in fact. Maybe I have learned something in medical school after all.

The best day of medical school ever

Yesterday the med students and ER interns met at a state park on the shores of a lake. It was a lovely summer day, not too hot or humid (something we were very grateful for by the end of the day). We started off with a brief talk on wilderness medicine. One of the topics was how important duct tape is. The speaker said that part of the fun would be seeing how we would improvise with it during the exercises, but there wasn’t time to give the lecture on "formal" uses of duct tape. Looking forward to hearing that one someday.

We split up into groups of four and spent the afternoon running, biking, canoeing, and otherwise making our way from one checkpoint to another. At each checkpoint we had a medical emergency to manage, overseen by one of the instructors. At some stations one of the team would get a card with instructions on being the victim. They also brought one of the CPR simulator manikins. My team ("The Intubators") was all young guys--in fact, I was the only member of the group older than the average age of the group. So I wound up really having to push it to keep up with the young 'uns. And it was a race, so we had to make time both getting to the stations and efficiently managing the crises.

We started off running to where the bikes were, and before we even got there one of our group got "disoriented" and "belligerent" and had to stop. The director of the residency program was standing there with a clipboard to see how we managed heat stroke. Then we got on the bikes for a five-mile ride interrupted by a bow hunting accident (yes, as we pulled up the paramedic handed one of us an arrow!) and a broken shoulder/arm. We used our multipurpose tool to perform a thoracostomy on the arrow victim, then made a one-way flutter valve out of duct tape for the wound. We also used much duct tape over the course of the day for splints.

As soon as we got off the bikes we had to deal with a woman who had been run over by an SUV in the parking lot. By this time we were starting to feel the pain, and it was getting a bit harder to focus on proper medical management. Which was the point, of course. The woman died, unfortunately, but there was no time to linger--we had to run down to the beach to deal with a diving accident. The victim was floating face down in the water with a possible C-spine injury.

After getting the diver to shore on a back board we had to cross the lake with two guys in a canoe and two in a paddleboat (because you never know what you'll have available in a real emergency). Turns out it's very frustrating trying to cross a lake in a paddleboat when you're in a race--they're maddeningly slow. On the other side we came across a dramatic scene. The instructors said that a sudden storm had come up. There was a flash of lightning and two young boys were lying on the ground up the road, one of them not breathing. We ran over, making our plan for two-man teams, but when we got there we found a third victim behind a tree. The victims were played by the sons of one of the people in the department and they did a great job. The boys had a great time as we performed "CPR" and splinted them.

We had to bushwhack up a hill to the next scene. At the top we dealt with a broken leg. We had to splint it and then carry the guy 100 yards. Unfortunately the chosen victim in this scenario was the biggest guy on our team. Finally we ran back down the hill, got back in the boats (we didn't have a proper place to land and had to lower the canoe four feet into the water, during which the canoe tipped and dumped me in the lake), and crossed the lake back to the finish line.

When we got back there was food and beer, and then they read the results. Each of the six teams' times were announced, along with penalties (such as 2 minutes added for making a mistake in managing a trauma). We came in second place (six minutes out of first place--if we hadn't tipped the canoe we would have won!). There were also awards for things like Best Splint. I got a best acting award for my portrayal of a clavicle and humerus fracture. Everyone agreed that this had pretty much been the best day of medical school for all involved.

Survivor: Final Exam Edition

Tomorrow is the last day of the emergency medicine elective that has occupied me for the last four weeks. It's been a wonderfully educational and colorful month and has certainly piqued my interest in the field. Usually clinical experiences like this end with a final exam, often a quite difficult one. However, there's no final exam this time!

So does that mean that we're off the hook? No, medical students are NEVER off the hook. Allow me to quote, verbatim, the e-mail from the course director regarding our activity for the last day of class:

Just a brief note about Fri. We’re planning on starting at 11 am at the beach lodge at ________ State Park. I thought about requiring you to bring the classic “10 Essentials for Surviving in the Wilderness” http://seattlepi.nwsource.com/getaways/216076_essentials17.html , but thought that was too hokey. Required equipment for each participant will be 1) Drinking water, 2) Bandana, 3) 4 Safety pins, 4) Sunscreen 5) 25 yards of duct tape, 6) Clothes that can get really wet and dirty (a change of clothes isn’t a bad idea either). Each team should have a compass and a multipurpose tool- let me know if you need to borrow one. You’ll get a course map and race rules once you are there. Disciplines may include running, biking, swimming, canoeing, improvising, and sweating. I’ll have some food and beverages for dinner, but you may want to bring something for snacks and/or eat ahead of time.

See you at 7 am tomorrow.

Of course, I'll take this over an exam any day of the week.

Tornado Liveblogging, Part 2

The weather here just got really bad and the National Weather Service is reporting a tornado on Doppler radar near one of the sites where Lady M works. Fortunately she's at another job site this evening. (This isn't a duplicate post--this is the second evening in a row this week of tornado activity in the vicinity!)

UPDATE (19:48) -- Spectacular bolt lightning and scary fast-moving very low clouds overhead, but otherwise seems less stormy at my location than yesterday Monday. The NWS reported the tornado to be moving at 45 mph, so if it was on the ground it's moved on by now. I've called Lady M; waiting to hear back from her. Hoping she's in the basement.

UPDATE (19:51) -- NWS confirms that the tornado is now on the other side of town and moving away. Our tornado warning is scheduled to expire in 10 minutes.

UPDATE (20:01) -- Worst of the storm seems to have passed (although you have to be careful, since tornadoes often form at the trailing edge). The local paper's web site covered last night's Monday's storms, but tonight's doesn't even show up on their home page. (I guess when you live in Iowa, there have to be at least two tornadoes on the ground before it's news.) NWS now confirms that the storm has moved out of the area and the tornado warning has expired.

UPDATE (20:12) -- It's quiet now and the rain has stopped (although it's very dark to the southeast, which is the direction the storm was moving). The NWS has this cheerful message for us:

BE ON THE LOOKOUT FOR RAPIDLY 
DETERIORATING WEATHER
CONDITIONS. SEEK SHELTER IF 
THREATENING WEATHER
APPROACHES. ALSO BE ON THE 
LOOKOUT FOR FLOODED ROADS
AND STREAMS. TURN AROUND...
DO NOT DROWN.

LATE UPDATE (21:42) -- Lady M is fine, the storm is long gone, and no reports of injuries or damage.

Jaws of Life

To help us learn about what happens to patients before they arrive in the Emergency Department, on Monday our group of med students and interns went to the city's firefighter training center. And, boy, was it cool! We started off learning the basics about the lingo and equipment of firefighting and rescue, which was fascinating enough. But then it was time for us to do a mini version of the training that the firefighters undergo themselves.

It started off in the SCBA (Self-Contained Breathing Apparatus) Confidence Course. This is a custom-built second story loft in a vehicle barn. It's about 50 feet square and only about five feet high inside (so you can't stand up straight). The interior is a maze of low plywood walls, gates, rooms with furniture, and all sorts of obstacles such as large plastic tubes and tangles of wires. And once the door is closed, there's no light. Several manikins representing fire victims were pre-positioned in hard-to-find places (under chairs, behind obstacles). We then divided into groups of three. Each group had to crawl through this maze in the dark, locate the victims, and carry them back to the starting point. And, since structural conditions in a burning building are constantly changing, the instructors latch and unlatch plywood gates behind the teams--in other words, you can't get back the way you went in. Best of all, the instructors brought out the infrared scope, so those of us waiting for our turn could watch the ghostly thermal images of our colleagues stumbling through this maze. (Eerily, the scope shows the reflection of each person's heat in the corrugated metal roof.) It was very hot, and we had the luxury of wearing summer clothes; the real training is done in full protective gear with oxygen tanks. And, of course, the building wasn't really on fire. The point of this is to keep trainees' nerve up when facing a dark, unfamiliar environment, as well as to practice getting around in the dark in a complicated space.

Next, it was into the Buckman Box. This is a custom-built wooden structure measuring about 40 x 30 x 20 feet. It features ceiling/floor platforms that are hinged so that their angle can be changed, and doorframes that are not square--again, this is to simulate conditions in a building that has lost its structural integrity. Basically, you climb through an 18-inch hole up a six-foot, 45-degree ramp to get into the box. Inside it's a three-dimensional maze of sudden sloping dropoffs, ladders into attic spaces, dead-end crawlspaces, and other obstacles. All of this is done on hands and knees or crawling on your stomach. And all in the dark, natch. In fact, there are several paths through the box and you might come out any one of several exit points. Half a dozen of us would crawl in at a time and then gradually emerge from various holes.

Finally we were taken outside to a row of junked cars. Yes, it was time for the vehicle extrication exercise! We suited up in helmets and protective gear and then went through the process of stabilizing a vehicle and opening it up to remove trapped drivers and passengers. We got to use the hydraulic rescue tools, including cutters and spreaders. They taught us some of the finer points of shattering tempered glass, popping car doors out of their frames, cutting through window posts, and pulling up dashboards to get trapped legs out. It was fantastic! And we got an added dose of realism, because while we were out there it started to rain. And then started raining hard, in sheets. And then the lightning started. All the while we're taking hydraulic and electric tools to large chunks of metal. As the instructors pointed out, conditions in the field can get a lot worse than that. But it was still an impressive storm; this one wound up spawning two tornadoes.

Truly one of the most memorable days of medical school.

Why does Ben-Bob wear red suspenders?

What with all the tornado action yesterday evening I didn't even get to describe the day's main event. I've got an ER shift tonight (and then I've got to read and analyze some journal articles a for a public group debate at school) so I'll have to write about it later. Until then, suffice it to say that the day involved wearing a firefighter's helmet....

Tornado Liveblogging: Late Update

Spoke too soon earlier. There was some tornado damage in a town about 20 miles south of here, but no injuries reported. Most of this part of the state is under tornado watch/warning this evening, and there's very heavy rain and near-continuous lightning at the moment. Some local waterways have been approaching flood stage and the NWS is reporting "ponding" on area roads.

Tornado Liveblogging

Severe thunderstorm directly overhead, tornado on the ground 10 miles west of here, moving south. Venezuelan neighbor just went down to basement laundry room. Of course I've been standing in the entryway, listening to the fantastic thunder effects we're getting.

UPDATE (16:51) -- National Weather Service says the tornado is about to get to the town where we used to have a storage unit, about 10 miles south of here. The storm is no longer directly overhead. There's a delay between lightning and thunder (earlier the thunder was instantaneous, very loud, and had a whiplike echo). Also, the sickly green storm color has gone away (fellow midwesterners will know what I mean). Spotters are reporting golf ball-sized hail at the nearby mall.

UPDATE (17:02) -- Storm has definitely passed over my neighborhood. Significant lightning/thunder delay now, and thunder is much more muffled. Tornado warning ended at 17:00, tornado watch continues until 23:00. We're also under a flash flood warning until 22:45, which should be taken seriously; when I was driving home the streets were under so much water that cars were starting to have some trouble getting through.

UPDATE (17:09) -- No reports of injuries or damage. As far as I can tell from the NWS, there is no longer a tornado signal per radar. Still stormy, but now just an ordinary summer thunderstorm.

UPDATE (17:24) -- Des Moines Register News Service confirms "at least two tornadoes that touch[ed] down briefly and harmlessly" in rural areas of this county and a neighboring county.

Residency on Ice

Much of the medical education process has left me with the vague feeling that there's a secret rule book out there somewhere that I was supposed to read but never saw.

For example, I'm currently making a list of residency programs that I will be applying to, so I've been spending quite a bit of time reading their web sites. They often have profiles of their current residents, which can be a very helpful indicator of whether one might be a good fit in terms of background, competitiveness, etc. In fact, the profiles are often blurbs written by the residents themselves. A popular format is a questionnaire, and a common question is "What was the most interesting job you worked before medical school?" Oddly, several times already I've come across the answer "driving a Zamboni." Really!? Is this a common job for pre-meds? Is it considered a reliable guide to one's future performance as a resident physician? Are there really that many biochemistry majors across the country resurfacing ice rinks?

I honestly have no idea what to make of this.

Vital Organs

When I showed up for a recent shift in the ER there was a neatly-sealed box sitting on one of the desks labelled "Dr. ____, HEART." Guess what was in it?

Just before I arrived a trauma victim had been there who had also been an organ donor. Time is of the essence with donated organs, and the box was waiting for a designated transport person. As I stood there I heard one of the senior nurses tell the other personnel that there was also a set of donor lungs in special storage in another room and to be sure to let the transporter know about them.

About five minutes later the transporter arrived, got his instructions, collected the box, and filled out the paperwork. As he turned to go somebody shouted a reminder: "Don't forget your lungs!"

Renewal

Today I walked past a tree next to the sidewalk. In the middle of the dark green leaves I noticed a small bunch of dead brown leaves hanging straight down from the end of a half-broken branch. But then my eye was caught by a bright green shoot growing up out of the wound at the break. An image of healing on the way home from the hospital.

"Good job!"

When I started my clinical rotations, I noticed something that grew to bug me. In many areas of medicine, people hardly ever say "good job." Not that we should be insincere, but when somebody does, in fact, do a good job it's a helpful and widely-followed convention to acknowledge it by saying, well, "good job." But not so in the cathedral of healing. Most days, you could save someone's life by repairing a brain hemorrhage using only a printer cartridge, four paper clips, and your car keys, and nobody would say "good job."

Which brings me to something I'm really enjoying about my current rotation working with ER people: they acknowledge a task performed well. They're also good about providing constructive criticism, but in a supportive way.

Good job, Culture of Emergency Medicine. Good job.

Med student's perspective

I've been ruminating on yesterday's post regarding simulated patients (SPs). Now, it's true that many medical students are, in fact, young, inexperienced in certain areas, and socially awkward. But there's more to it than med students being newbies who are stressed out by their inexperience with the undergarments of the opposite sex. So I thought it might be interesting to offer the medical student's perspective on the encounter.

Imagine that you need to perform a complicated task for your job, one that you have little experience with. You're asked to perform the task with a trainer. The task consists of 100 steps, each of which you must complete, in order, with your boss watching and listening via a swivel-mounted video camera and marking each mistake or deviation on a checklist. The video recording will be archived and reviewed by a committee of your supervisors (and peers, in some cases). The results will be entered into your permanent record, available to all of your future supervisors when you are considered for future promotions and raises. All in all, nervousness is probably a perfectly reasonable response.

Although medical students are often placed in situations where they will feel nervous, it is important to learn to control those nerves for the patient's good. And as students, of course, it is only natural that part of the stress of working with SPs comes from unfamiliar intimacy with a stranger in what is already an artificial situation. But I can say from experience that the stress of an SP encounter is often much more intense than that of encounters with actual patients. I appreciate the SPs who have contributed to my own medical education, and I thank them for it. I'm glad that my first rectal exams, genital and breast exams, and general physical exams were not performed on real patients, and instead were taught to me by well-trained, generous simulated patient instructors. But I'm also glad that now most of my face-to-face histories and physicals are with real patients seeking real care, without the whirring of a video camera on the ceiling tracking every move.

That one Seinfeld episode

Last week there was an article at Slate.com--"Playing Doctor" by Emily Yoffe--in which she describes her experience as a simulated patient undergoing physical exams from 23 medical students at Georgetown School of Medicine. As fate would have it, today my group worked with simulated patients ourselves. I observed and evaluated one of the interns as she worked up a simulated case, and in turn was observed and evaluated while I worked up a chest pain scenario. Nobody involved had read the Slate article, but most people seem to remember that one Seinfeld episode.

Oooops.

Looks like I had accidentally turned off the comments. Should be fixed now.

Some Like It Hot

As somebody who spends much of his time in the hospital, I usually don't have to pay too much attention to the weather. But I'm a compulsive checker of the National Weather Service's local forecasts. Is it because of their forecasting accuracy? Their up-to-the-minute hazardous weather updates? Their cool, real-time radar imagery?

They've got all that and more, but what reels me in is the fact that they don't just tell you what the weather will be like; they show you a picture of what the weather will actually look like. And these are no silly smiley sun faces or clouds with lines falling out of them. No, each NWS image is a beautifully-rendered miniature masterpiece of atmospheric art. Consider these actual images lifted from the NWS site:



This one says "Let's pack a picnic lunch, but don't forget the sunscreen!"



This one says "Better bring the umbrella."



This one warns of the most delightfully-named weather they've got, "wintry mix."



This one says "It will only be safe to carry long metal poles around outside 20% of the time."



"Don't carry those long metal poles around at night, either."



This one predicts perfect weather for alternate forms of sustainable energy production.


But there's one that truly scares me when I see it:


This one says "OMIGOD THE SUN'S GONE SUPERNOVA THE OCEANS ARE BOILING OH NO MY EYEBALLS ARE VAPORIZING.... [Transmission from Earth ends.]"

Check out the atmospheric prognostications for your locality (including those readers in Pago Pago) at http://www.weather.gov/organization.php.

Flatline

Today I had the exam for my Advanced Cardiovascular Life Support (ACLS) class. I was tested with a group of five other med students and interns. I was chosen to go first. Each person had to "run a code," i.e. oversee a team of people attempting to resuscitate a patient. My case was commotio cordis, in which a blow to the chest causes a disturbance of the heart rhythm. In this case the scenario was a 15-year-old pitcher who got hit square in the chest by a line drive and went down, unresponsive.

Although only a simulation, it's both exhilarating and nerve-wracking for someone like me who has had relatively little experience with emergency medicine so far; there's a lot to keep track of. I can only imagine what it would be like to have a real 15-year-old on the ground with no heartbeat. I was wracking my brain for things to do (and asking the rest of the team), but in these cases death is the most common outcome and this was no exception. Even in a simulation it's unpleasant to lose a patient.

At the end the instructor gave me a good evaluation, saying that I stayed calm and directed everybody through the resuscitation algorithms clearly. (We "did all we could.") I'm not sure it felt so smooth from my point of view. I have to admit that I'm both anticipating and dreading the first time I do this for real.

Teen surgeon surrenders

A 15-year-old in Tamil Nadu has surrendered to authorities after allegedly performing a C-section. His parents, both doctors, were arrested last week. Evidently his father wanted to get the kid's name into the Guinness Book of World Records as the world's youngest surgeon.

Who says that doctor types have overly-competitive personalities?

Do we land this plane or not? Part 2

When we left off we were considering the case of a woman who had just suffered an apparent in-flight tonic-clonic (grand mal) seizure; the flight crew needs an immediate decision on whether to make an emergency landing or not. At this point, most of the medical students in attendance at the talk said that they would not recommend diverting the flight.

In this case, the doctor decided to land. He said that the plane began descending almost immediately, and much faster than during a normal landing. As the descent started, the patient's condition was improving. She continued to improve during landing and taxiing, and wound up walking off the plane. The pilot thanked the doctor for his help, and the flight was turned around and airborne again in an hour, minimizing the inconvenience to the passengers. The doctor admitted that it was a little awkward to see the patient walk off the plane, but everyone was relieved that she was all right and that in the same situation again he would have made the same decision. (By the way, kudos to commenter Bethany for correctly diagnosing the patient's post-ictal state.)

At this point during the talk a resident spoke up to say that he had been in the same situation once. In this case a woman developed a severe headache, a symptom that could be relatively benign or could indicate a life-threatening condition. In this case the resident evaluated the woman and decided not to recommend a diversion. He also spoke with the woman's daughter (who he described as "hot" but denied that this had anything to do with his decision not to interrupt the flight).

A 2002 article in the journal Neurology concluded that "[n]eurologic symptoms are the most common medical complaint requiring air-to-ground medical support and are second only to cardiovascular problems for emergency diversions and their resultant costs to the US airline industry. Adding antiepileptic drugs to the onboard medical kit and greater emergency medical training for in-flight personnel could potentially reduce the number of diversions for in-flight neurologic incidents."

The Federal Aviation Administration states that "[c]ardiac emergencies account for the most diversions, followed in order by neurological, respiratory, and vasovagal cases. The diversion rate for cardiac cases is the highest, followed in order by neurological, obstetrical, vascular, and respiratory emergencies. Physicians responded to IMEs [inflight medical emergencies] approximately half of the time, while nurses respond about a third of the time. The medical kit was used in approximately half of IMEs. The stethoscope and sphygmomanometer were used over 700 of the time the kit was used, and nitroglycerin was used about five times as often as epinephrine or diphenhydramine."

Anecdotally, Paul Farmer once said that a request is made for a doctor on about one in every eighteen flights that he takes. Remind me to pack my stethoscope in my carry-on the next time I fly....

Anal Wink

Yeah, that's right, you heard me: anal wink. Y'know, I'm tryin' to run a respectable blog here, but then a buncha troublemakers have to go and start talking about anal wink in the comments.

Well, if you insist. Anal wink (a.k.a. the anocutaneous reflex) is the contraction of the external anal sphincter in response to perineal stimulation. Eliciting it can be a useful diagnostic strategy for certain neurological evaluations. (At least, that's what trained healthcare professionals use it for. What you use it for is entirely up to you.) Do not confuse it with rectal tone.

Bottom line: it's a legitimate medical term, really. (Get it? "Bottom" line!)

Tomorrow: The thrilling conclusion to "Do we land this plane or not?"

"ERAS Electronic Token 2008"

Today my e-mail brings me a message titled "ERAS Electronic Token 2008." Wow, a token! I wonder what I can use it for? Consumer electronics? A bus ride? Ah, this cryptic and unexciting phrase will take me on a ride, all right, but not necessarily an enjoyable one....

Those of you who had the misfortune to be hanging out with me while I was applying to medical school a few years ago may remember me referring to something called "AMCAS" (often prefaced with an adjective that shall not be reprinted on this family-friendly blog). This was an online centralized application system for applying to most medical schools, and was a source of much bitter amusement during that stressful, coast-to-coast slog.

Well, the time has come to begin the process of applying to residency programs, and that means it's time for another online centralized application system--ERAS! This evening I tried to log on for the first time, and after being scolded with a rather judgmental error message ("Bad ERAS login") began to enter my biographical data, info from my CV, etc. Then if all goes well later this year I'll be putting on my suit and heading out for interviews at residency programs.

It's pretty exciting, actually, but why is this tiny voice in my head whispering that all may not go as smoothly as one might hope...?

Tales of the ER: You talkin' to me?

The other night I'm in the ER, typing up a clinical note on the computer, and out of the corner of my ear I start hearing "What do you think you're doing here? Who let you in? This guy doesn't belong here." It didn't really register at first; the workspace is roughly the size of a small living room, full of about 20 stressed-out, fast-moving people, and strange things happen all the time. So I just keep typing, concentrating on remembering how to spell "resuscitation" (a personal block I've been having recently).

However, I quickly get the weird feeling that the comments are being addressed to me. And that can only mean trouble. Sure, it might be a crazed sociopath, preparing to act out his horrific and sadistic hallucinations on me, but when you're a med student it's unlikely to be anything so benign. In fact, having just completed a surgery rotation, I was fully expecting it to be a crazed attending physician, preparing to act out his horrific and sadistic hallucinations on me.

But when I looked, it turned out to be my friend Craig, who manages the clerical staff of the ER, trying to give me a hard time. It's so nice to see a familiar friendly face in the midst of unfamiliar, stressful chaos. And he didn't do anything crazed, horrific, or sadistic at all. (Although he may have been thinking about it. Just for a second.)