Interviews Continue

In the process of making some of my last reservations for airfare and hotel, I cannot help but think about how fortunate in these ever-worsening economic times we senior medical students are to have a say in where we will work next year. It seems more of a pain than a privilege to have to jet across the US in search of the best-fit residency. But as each interview unfolds and as I'm toured the guts of America's hospitals, and as I observe how emergency departments operate on this coast or that, I feel tinges of conflict. Here I am with great opportunities - only one of which I will pursue - while the patients I'm chomping at the bit to meet, treat and advocate for face the converse: evaporating opportunity, escalating suffering and vanishing resources.

When framed this way, I ponder canceling the rest of my interviews. My pro&con lists from each program pick out relatively small differences between places. In the end, I know I must continue on for another few weeks. While the next month may consist of greenhouse gas guilt, travel fatigue and missed loved ones, the four years of residency will consist of lost sleep, steep learning curves, stresses of responsibility and the anguish of bearing witness to great pain and suffering. It will be important to live in a context of a supportive environment. Academic, social and even political and geographic context will play a part in my decision to rank programs. After then, it is up to the big computer in the sky to decide where is best.

We Escaped!

We flew on a different airline and to a different city than initially planned, but on Sunday night, my wife and I escaped the clutches of the winter storm currently incapacitating Seattle. I overheard one Southwest Airlines employee say we were the last plane to leave Seatac. I'm not sure if that was on Southwest, or in the whole airport. I wouldn't be surprised if it was the latter: we had to wait for more than 30 minutes just so the snow could be cleared on the tarmac between the plane and the runway. Our departure insured that our luggage did not make it into any "sorry, your flight was canceled, please collect your belongings in baggage claim" collections like this:


Susan was able to get to her interview at UCSF on Monday. I spent the day in the UCSF emergency departments for a 'second look.' Today, I interview across the bay at Oakland's Highland Hospital.

There are several reasons to be glad not to be in Seattle! It would be fun to play in the snow and all, but it turns out there's a reason why the city couldn't handle an inch of snow last week: Seattle refuses to use salt on its roads and the sand they do use is not enough to ensure safe motorist transit. The stated reason is the salt might impact Puget Sound's endangered salmon populations. Some biologists argue sand is actually worse because it fills the spaces between streambed pebbles such that insects and other fauna important to waterway health perish. Seattle is the only municipality (according to one article) that has a ban on salt. Sand is also 20% the cost of salt. My guess is that only the tincture of time and climate would benefit this picture:

With grades up to 20% in places, it's Mr. Sun who can restore normalcy to Seattle. Given this time of year's 8 hours of sunlight and perpetual winter clouds, I wish everyone there a hearty good luck! That packed ice takes a lot longer to melt than the fluffy stuff the kids are playing in. From a distance, Denny Way looks more like a ski slope than a road. In fact, there were intrepid young men snowboarding down Queen Anne Ave., NE 70th St., and I'm sure many others.

Snow Geese and Flying Home

On this Solstice Eve, the Pacific Northwest is getting slammed with a winter storm. And winter storms, we do not need! On Wednesday night Seattle received 1-2 inches (in most parts of the city), and look what happened:

Yes, that is a passenger bus that slid down a steep grade and plowed through a guard rail resulting in a cantilevered installation over I-5. Note the topography in the background. It's a good thing Seattle doesn't get winter weather very much. Susan and I are visiting our parents for the next two weeks, and hope to be able to leave Seattle tomorrow by plane. We also interview in the Bay Area on Monday and Tuesday! We'll be heading to the airport by bus extra early to account for difficulties from the the expected 4-8 inches of snow. If you want to see the view of the weather, here is a webcam view from the NOAA station across the street from where we live.

But we wanted to experience just a little bit of the current snow, so just as this evening's snow started to fall, we took a stroll around the golf course near our apartment. We were surprised to see a flock of about 30 large white birds circle and land on a nearby snow covered fairway. Upon closer inspection, I confirmed that it was a small gaggle of snow geese. I can only assume that they were in transit from the North Slope of Alaska to winter grounds in California or beyond.

At the time of writing, the snow has completely obstructed our view across Lake Washington. Unlike this Seattle-softened Midwesterner, I expect these birds to know what to do in the cold...

Science News

Among many other strong choices for science advisers, it appears an outspoken advocate for curbing greenhouse gasses has been selected to serve as chief science adviser for the Obama administration. John Holdren, a past president of American Association for the Advancement of Science, had to cancel a meeting at Harvard to fly to Chicago. According to journalists who are familiar with these escapades, this probably means he is meeting with Obama about a job. The AAAS blog reports this, as does a NYTimes blog. About climate change, he says,

I am one of those who believes that any reasonably comprehensive and up-to-date look at the evidence makes clear that civilization has already generated dangerous anthropogenic interference in the climate system…. What keeps me going is my belief that there is still a chance of avoiding catastrophe.

Sounds pretty okay to me. He also was involved with Pugwash and was part of the crew that accepted a Nobel Peace Prize in 1995 for nuclear non-proliferation work.

What I want to know is if he will get an office IN the White House. You may recall that GWBush kicked his science advisers out in favor of them occupying space down the street.

Random Musings

• 14 gauge needles are huge.
• Work hours debates continue.
• Teaching is fun.
• An electrified skeleton of a deer is feeding on the tundra that is our balcony.
• Did I mention how large 14 gauge needles are? I mean, an arm vein with a 14 gauge catheter seems to lose more blood (and faster too!) than a catheterized wrist artery... I've the bloody scrubs to prove it!
• Must... Get... Out... Into... Sun.... SOON!
• Thanks fto an anesthesia rotation, not only do I now check out people's veins when I meet them ("Could I get a 16 gauge into that antecubital?") but I inspect their chins. ("Start with the MacIntosh, or go straight to the Miller?")
• There are plenty of real people out there that think about more than, well... see above.
• Soon, I will be pulled in only one direction: the beach.

Note to Self:

Hey Robey!

When you have the time, write some blog entries about the latest Papal statement ("Dignitas Personae,") about in vitro fertilization and stem cell science and some of the responses to it.

Or maybe something about the scandal of free religious expression in the Washington State capitol building.

Or even about how the magi's part in the Christmas story provides a pretty good metaphor for a healthy interplay between science and religion.

I'd imagine each of these to be a good fit over at Clashing Culture, the blog I started about science and religion, which I have sorely neglected in the past few months. In the interim, get back to work!

Eagles

One thing I know about wherever we end up next year after the residency search is that I probably will not be able to sit in my living room and take pictures like this. (This bird was probably 20 meters from my window.)


Granted this is an out-of-focus shot with a point-and-shoot digital camera, but that I can see this on a regular basis from where I type away on my various projects is one of several reasons why my wife and I will miss Seattle. I just wish I could have gotten the snow covered mountains or Lake Washington in the background of this shot. But really: yesterday, I saw a bald eagle, a red tailed hawk and a Cooper's hawk in the span of a few hours.

Intubation

Today, I intubated my first (human) patient. I used a MacIntosh laryngoscope to displace the epiglottis so that I could insert a breathing tube down a patient's windpipe (trachea) so that she could be comfortably anesthetized during a surgery to remove her thyroid. The anesthesiologist had let me insert the plastic tube twice on other patients while he held the blade. He then let me do #3 from start to finish. #4, however, was not so successful. The patient's short chin and other factors made for a difficult process. At least I got one!


And let me say, my experience ventilating mice was not of much use as preparation. (I've probably intubated 750 rodents.) In the case of the mouse procedure, a cotton swab is the laryngoscope and a 10-100 piece of beveled tubing is the endotracheal tube. Evaluation of proper intubation (visualizing vocal cords, seeing fog on the inside of the tube and symmetric chest inflation) is however the same...

I can usually put patients at ease when I sew up their cuts if I say I've lots of practice stitching mice. Based on today, neither anesthsiologist nor patient will learn of my previous 'experience' with rodent intubation...

Delta Work Hours?

Last week the National Academies' Institute of Medicine released a report recommending that medical resident work hours be curtailed even more than they were five years ago. This is based on some pretty solid research, mostly from a sleep study group at Harvard. The report is the subject of my latest post at The Differential, which if you're in academic medicine, you should definitely read (if not my post, the report). Unfortunately for me, if the accreditation group makes any changes it will likely be AFTER my intern year when I'm expected to work 30 hour shifts...

Update 12/9/08: My post is getting a lot of comment activity, particularly from resident surgeons who are proudly defending the fact that they violate their 80 hour limits and love it! Check it out! By the way, Pauline Chen at the NYTimes wrote a biased "I didn't have work hours limits when I was a resident and I turned out just fine, thank you!" article about this issue. And there is lively discussion of the topic at the Times' Well Blog as well.

4th in 5 Days

I'm in NYC ready to interview at the NYU/Bellevue emergency medicine residency. It's my 3rd city in 4 days, and tomorrow will be my 4th interview in 5 days. On my day off, I observed for a few hours in the New Haven hospital before going by Amtrak to NYC. I'm not particularly tired, but I do miss being home. Some things that have made this trip easier include:

• Traveling by train in the northeast is easy: show up at the station, get on the train, work in peace and quiet for a few hours, get off the train & you're there.
• Staying with friends from med school is great. Since I took 4 years to do my PhD, my classmates are all 4th year residents and therefore very knowledgeable hosts. It saves lots of ca$h, too.
• Traveling light is a must. For me, that's a bike messenger bag and a shoulder garment bag.

Negatives include:

• Not seeing or talking to my wife much - The three hour time zone difference further complicates the fact that she is working a night shift and sleeping days, and "everything's in a fog" for her.
• Gum on transit seats. Bad form folks... If only we were in Singapore! My impromptu road extraction kit lacks a key solvent. Hopefully the friendly neighborhood dry cleaners will be able to help me next week. My evaluators will have to look REALLY CLOSE at my backside to notice the gum remnant!
• Answering the SAME QUESTION over and again. At least my response stays the same each time.

Well then! Enough from me...

Dr. Goatee

In searching the internet for possible residency interview questions, I stumbled upon some other 'tips' about interviewing. Most notably, one site from Rush University offers the following prescription for a successful personal presentation:

Dress should always be conservative, tasteful, neat—and comfortable.

Have the appearance of a successful, mature physician, not a medical student.

MEN should wear a suit, not sport coat or khakis.

• Navy or gray, solid or pinstripe.
• White or pale-blue shirt.
• Conservative tie: solid, stripes, or small pattern (red or navy).
• Keep jewelry to a minimum.
• Short hair, preferably no goatees.

It's not just the Chicagoans at Rush that offer this advice. I found websites penned by schools from LA to Boston arguing for a clean shaven face. But there are other things I noticed about these suggestions:

Dress should always be conservative, tasteful, neat—and comfortable.
Okay, I buy this. Comfortable helps when you're running to catch your next flight, too.

Have the appearance of a successful, mature physician, not a medical student.
I think I have this down, what with being older than most of the residents at some programs; in five interviews (three schools, so far), I've received the follow-up question, "How old are you?"

Men should wear a suit, not sport coat or khakis.
Okay, I'll give here. Although when I interviewed at UW for the MD/PhD program, I wore khakis and a tie - no jacket. Look where that got me!

Navy or gray, solid or pinstripe.
Evidently black is out?

White or pale-blue shirt.
Whoops again. I don't own white or pale blue.

Conservative tie: solid, stripes, or small pattern (red or navy).
My real goal here is: not ugly.

Keep jewelry to a minimum.
Nickle allergy keeps this in check for me.

Short hair, preferably no goatees.
Does a shaved head count for short hair? Maybe shaving up there will cancel out the apparent transgression I make with this:



I did end up shaving, but it was the top of my head...

EM Interview Questions

There are a number of standard residency interview questions that candidates are asked in the interview circuit. A Google search will provide you with some stock questions you should be prepared to answer. For various reasons, I tend to take advice from those sites with a grain of salt. So here are some actual questions I've been asked on my emergency medicine residency interviews.

• How did you decide to apply to our program?
• Where will you be in 10 years?
• You've a different background than many applicants. Describe your trajectory in deciding on emergency medicine.
• What have you been reading?
• What is Wunderkammern? (A hobby I listed on my application.)
• So! What do I need to know about you?
• Which of your letter writers do you admire the most?
• What questions about our program can I answer for you?
• How would you respond to (insert complicated ethical dilemma here)?
• What are you doing the rest of the year?
• What are your plans for the holidays?
• What courses are you enrolled in this year?
• Why emergency medicine?
  
• Where else are you interviewing?
• Why (insert city here)?
• What will your first book be about?
• How have you responded to a situation of personal conflict?
• What areas of emergency medicine need the most work?
• Do you want to go back to Seattle to practice EM?
• What do you do to relax?
  

I'll give periodic updates to this list. I've only interviewed in three places. Do any of you co-applicants have any additions?

Titles

A few weeks ago, I shared what would I thought could make a good title for a book. I still like it a little while later, but am thinking that catchy isn't the only requirement for a title's success. The content has to be interesting, too.

My recent extravagance in carbon expenditure - also known as residency interviewing has triggered some interesting publication ideas. Of course, the best idea has already been acted on by another frequent flier. Fortunate to get window seats in the exit row for my past 3 flights, I could concentrate on the view below rather than avoiding broken patellas or DVTs. And I got to thinking that the maps in the back of the airlines' magazines hardly provide useful information for the curious window-sitter.

So why not publish a guide to the most trafficked flight corridors that explains where you are, the topographic formations, and cloud formations from 35,000 feet?

One good reason is that other folks have already thought of this. A title printed in 2004 (Window Seat: Reading the Landscape from the Air) and one in 2007 (America from the Air: A Guide to the Landscape Along Your Route) look to be complementary resources for the curious traveler.

Both look interesting, so I put them on my Amazon Wish List. Maybe there is still room for my ideas, but the core concept has already been done... One author even thought about providing an interactive CD for use in your laptop! (My idea was to adapt my book for a handheld computer.) So much for my business plan! I should stick with medicine.

Inner Viewing

You can expect my posts over at The Differential to focus on interviewing for the next few weeks. After I finished my interview at the UCSF residency last week, I jotted down a few tips for future interviews. The article is now up over at the MedScape blog.


Stay tuned for more tips. Both here and there!

Obama Lit 101

In real life (i.e. not on this blog), I'd been pretty critical of John McCain's medical history of melanoma so was pleased when he released his medical records, limited that they were. Back in the early primaries, I was equally critical of Barack Obama's smoking habit (correction: smoking addiction). That issue just faded away. Where is it now? Evidently, Obama may still be smoking. Michael Kinsley of the Washington Post thinks it's okay that he's fibbing about quitting. I'm not so sure I agree with that, but I am sure about it not being okay that the next president smokes. We need some health advocacy groups to jump on that (if it's true).

What have you heard about the next president lighting up?

Today is the Day

Today I interview at UC San Francisco for a spot in their emergency medicine residency. It is the first interview of many for me, but is one of my very top choices. I've spent the last month working in San Francisco General Hospital, and really like the place. Granted, it's the only academic ED I've worked in thus far...

Well then... Here goes!

back to days

brain is jelly.

granted, it's spicy cranberry jelly.

jelly none-the-less.

perhaps returning to daytime shifts will help me out!

This is What I'm Signing Up For...

Several of my friends have suggested I respond to Pauline Chen's recent article in the New York Times about the treatment of medical interns during the first year of residency. Her article is provocative, and I am planning to offer a response (from a soon-to-be intern), but am still digesting it. Stay tuned.

Really Tough Stuff

Lately, I've been complaining about the residency application process on this site and elsewhere in the non-digital world. It's been nice to be on rotation and have daily reminders of why you are going through the cumbersome process. Sometimes however, giant "reset" buttons come your way. Gianter (grammar intentionally misused) then catching a DVT or sewing a laceration, and not quite like the reset weekend to help me switch from day to night shifts that I wrote about this morning.

The reset I'm referring to tonight is more important. Today I visited a blog that I had not been to in a while. It's Ben Towne's online journal.


Ben is the three year old son of one of the pastors at the church I attend. He was diagnosed with an aggressive neuroblastoma last August (2007). Ben and his family have endured ups and downs of treatment and remission, hospitalization and time at home. They have had a large body of supporters, many of whom may have never even met Ben. I count myself as one of the folks who first heard about the family's story in a pew and have followed it by periodically reading the blog.

Much of the art of medicine is related to empathy with patients and families we encounter them in the hospital or clinic. It's a gift to be able to achieve this emotional skill, and it's one that can always find a new place in the physician's toolkit. There is even more to learn from witnessing non-medical aspects of patients' experiences. Some people go into medicine because of these experiences: a grandparent who may not have received the best care, a sibling who couldn't be saved from a disease, or a friend who was paralyzed in a car accident. I was not one of these people. That's why it has been a privilege to follow along with the Towne family's trials. Their web journal also makes it easier for me to think about and pray for them.

After aggressive radiation and chemotherapy, Ben's tumors are back with a vengeance. There is little that medicine can do for him except control his pain. The family has taken him home from the hospital and will pursue comfort care for him. By any account they have a tough road ahead of them. Yet, the journal reports this week that:

Many times last night Ben told [his mom] not to worry and that he loves her.

If you are inclined to pray, meditate or reflect about Ben and his family, I am sure that the Townes would appreciate it.

Fog Horns

It's a reset weekend.

After doing mostly 6AM to 2PM or midday shifts, my schedule necessitates my transitioning to an inverse circadian rhythm. After two days off, I have one 2PM to 10PM shift, and then five 10PM to 6AMs. Just like flying across country there are a couple of tricks for adjusting that I'm trying to follow. Today, I:

• Slept until 9:00 AM
• Plan to have a late breakfast
• Am contemplating each toot of a distant foghorn
• Will take a midday bike trip (via BART) to my parents in the East Bay
• Plan to eat dinner as my second meal
  
• Anticipate catching up on my writing late into the night

Tomorrow, I plan to:

• Sleep in even later
• Wait for the (forecasted) morning rain to cease before returning to San Francisco
• Take an evening jog
  
• Eat lunch, dinner and a late night snack
• Study some topics in emergency medicine
  
• Sleep from 1AM to 9AM (Monday)
  

Then I'll have to figure out where is the best place to sleep during the day...

A similar plan worked for me when I flipped from 12 hour day shifts to the converse while working at Harborview. Stay tuned for the outcome.

Interviews!

Wow!

The stress of the interview season is still crescendoing for me. I've a couple of rejections, a fair number of invites (see column at right) and a couple of programs I still haven't heard from in cities where my wife is very interested in training. Now that she is heading off for her first trip (New York, Baltimore, St. Louis, Boston, Chicago in two weeks), I'm of course antsy. Trying to fit in a couple interviews in each of the cities she likes is maddening! Especially when there are optional but strongly recommended social activities the night before or after the interview, making logistics quite painful. And I haven't even started to purchase airfare!

So it goes. I am glad to be in San Fransisco learning more emergency medicine and seeing how a residency works. Being from a city without a residency program is a real handicap in terms of knowing what to look for and assessing for fit. I'm having a great time here in spite of the stress of organizing a travel agenda. Any readers out there having the same struggles?

Health Care PRN

Will all of our pre-election excitement be lost to follow-up?

Now that there's a new guy headed to the White House, it's time to put some of those ideas about improving access to health care on the line.

I ramble about this and other topics over on The Differential today. Thanks for reading.

My First Rejection

The University of Pittsburgh declined to interview me for their residency program, but there are a couple of others who have extended an invitation (see running panel at right). I'm still playing the waiting game for the other 20 programs...

And I'll still root for Pitt basketball and football...

It is Finished

And so it came to pass that on Nov. 4, 2008, shortly after 11 p.m. Eastern time, the American Civil War ended, as a black man — Barack Hussein Obama — won enough electoral votes to become president of the United States.

Read the rest of Thomas Friedman's editorial here.

Obama

Good for health care

Good for peace
Good for science & innovation
Good for education
Good for the environment
Good for a better society

I guess those are the main things I care about when I go to the polls. My remaining hope is for:
An Obamaslide

Make your own logo at Logobama.

And no matter your political preference, make sure you vote today.

Bummers

How would you feel if after being treated for a traumatic car accident, the ER doc comes back to tell you there's probably a tumor in your lung?

The Daily Commute

or, "How Biking in San Francisco Reminds Me of Rugby"

After a week of commuting between San Francisco's Haight-Ashbury neighborhood and the Mission by bicycle, it occurred to me why I'm having so much fun going to and coming from work: it reminds me of rugby! Some readers may know that I played rugby for three years at the University of Pittsburgh. It was a club sport and I played on the B-side for all but the last 4 months or so, but I stuck with it because it kept me in shape, I was always learning new strategy and it was certainly a good way to release stress during difficult semesters. After I realized the other night that commuting by cycle provided the same thing for me here, the similarities just kept piling in. Here's my running list:

1. Both are excellent sources of aerobic exercise.
2. Biking safely in SF requires the hyper-alert mental status that keeps a rugger from getting clocked.
3. Ruggers and bikers must remain aggressively protective of their space.
4. This is the first time since rugby I've consistently worn stretch pants.
5. I get up really early to ride.
   
6. I work out late at night.
7. Showers twice a day in odd locations.
8. Climbing Haight St. kind of reminds me of running stairs.
9. Avoid taxis at all costs.
10. "Why are all of my clothes sweaty?"
11. There are some rules that must always be followed and there are others that you can get away with breaking most of the time.
12. There will always be folks who are much faster, in better shape, have more skill and are harder core than I.
    

Well, that's all that comes to mind for now. The bottom line is that I'm having a great time in SF, even if it's mostly consisting of working long hours, staying in to study and commuting between the two. By the way, I found this excellent website that plots a course between A and B on a bike that takes into account hill grade, total distance and more.

Medic Ride-Around

I just returned from 10 hours on a paramedic rig in San Francisco. This is part of the emergency medicine rotation at San Francisco General. It was a rather interesting day. Not very busy, but busy enough that I only napped for 10 minutes around 1:30 PM.

The cases included:

1. A morning commuter who fell in a crosswalk, skinned her knee and was bleeding from the head.
2. An older gentlemen one week out from a prostate surgery who had bloody urine and pelvic pain.
3. A kid who fell in gym class onto a tennis court and had midline neck and back pain.
4. An eleven year old who was post-ictal from his first seizure.
5. A different eleven year-old who konked heads with a classmate playing football.
6. An elderly diabetic woman who fell at the food pantry and incurred a non-bleeding scratch on her knee. She later offered to dance for us - for a fee.

Three of these went to a hospital. The medics apologized for not having any 'interesting' cases, but one pointed out that his favorite kind of day is one where no one gets hurt. It was interesting to me to see what people call 9-1-1 for, and the expense incurred for it. That's a difficult thing to get my mind around. And I'll have to think about that a little more.

Hello. I'm Thomas. And I'm a Blogaholic.

Okay.  It's time to dive head-first into the medical blogging controversy.  One of my colleagues at the University of Washington is interacting with administration there to possibly set guidelines and recommendations for medical blogging.  He's got me thinking again about this issue.  As you recall, I thought a lot (and still do) about the line between sharing a patient's story (anonymized) and respecting her rights.  I settle with asking patients or masking identifying facts so much that the patient would not recognize the account as his own.  You can imagine there are a lot of people who have things to say about this.  I respond to my professional society's position in this week's article for The Differential.  Check it out if you have the chance.

Regarding blogaholism, I actually do score positively on the CAGE screen for blogging (A and E).

2-10

Warning: humdrum domestic details ahead!

My first shift is today from 1400 to 2200. Last night I prepared by staying up until 11:00 PM. Today, I tried to sleep until 8 or 9:00. This morning, I'm reading emergency medicine stuff for a few hours, am soon going to track down some biking shorts (be very afraid) and a reflective vest, and will head over to the San Francisco General around 1:00 so I have time to shower and get my hair done. Then, since I have tomorrow off, I think I'll head over to the East Bay to get some computer work done. Now I just have to find a library where I can set up shop working on my various writing projects...

Next Stop: San Francisco

Well... actually, I'm flying into Oakland, staying with my parents in the East Bay and then heading over to SF proper to get the lay of the land before Monday's orientation to the San Francisco General emergency medicine clerkship. I'll pick up my brand new Trek 7.3 this weekend!!! My first shift is on Tuesday, I'll be riding along with medics on Thursday and much more. My overnight shifts are all grouped in my third week, which is nice, and I have scheduled my residency interview the last week of the rotation.

Now if I can just figure out what I need to pack...

Last Day

Today is going to be crazy. Just like the last 70 days.

After ten consecutive weeks of psychiatry, I'm going to miss hour-long interviews, the wait and see approach to care, the challenge of nurturing behavior change and all of the talking. I'll also miss the daily case studies of brain pathology.

• The amazingly disorganized schizoaffective homeless man who saluted me every time I asked him a question and could recount amazingly accurate historical accounts of the Pacific Theater in WWII.
• Entering into the dark, empty, wide-open room at the edge of a cliff and offering one pinhole of light (i.e. Washington Sate Law) to move a suicidal patient to the next day.
• Having to stand back when an extremely psychotic patient is immobilized for her own safety and then being there when she is able to speak in cogent sentences.
• Seeing the effects of drugs and alcohol that all of the commercials warn about.
• Learning that it's actually not uncommon for a manic person to be found naked, directing traffic. In fact, it's pathomneumonic for mania.

Psychiatry, you've been good to me. I'll see you again soon.

Diagnose This

For no apparent reason, I've woken up at 5:15 or 5:30 without an alarm for the past week.

I wonder if this application process is taking a toll on my sleep architecture.

Clinical Knowledge

My USMLE Step 2 Clinical Knowledge score came back in record time. As you will recall, my score on the costly sandwich (CS) exam was PASS. Today, three weeks to the day after taking the 9 hour computer exam, I received my score report. I PASSED, and scored higher than I did on Step 1 (which I took back in 2003).

Since my score was higher than I expected, and lower than most of my peers, I've decided to share some data about how well the USMLE World practice software package prepared me and the accuracy of one practice exam score predictor, provided by medfriends.org. Those who know I'm an engineer at hear will not be suprised by the following chart.

Plotted on this graph are score estimates from sequential practice exams I took using the USMLE World software. That software grants you acces to a couple thousand practice questions and prepares exams composing of 46 questions each. I averaged the raw scores of the six most recent exams made of questions I'd never seen. That average was input into the medfriends.org tool and plotted on the date. The averages are rolling. The turnover was 4 exams (adjacent data points share from 1-3 individual scores in their average. On the scale above, the horizontal line is 184, or passing. You can see that my trend was dangerously close to that cutoff. But considering my poor showing on Step 1 back in '03, I knew I needed to buckle down.

Shown in red is my actual score - a 209. This is below the national mean, but right about where I'd hoped to be. The one data point immediately before the exam - that was the free USMLE practice exam provided by the exam company. I recommend you take it. not only, will it make you feel better, my experience was that combined with the score estimator, it was a better predictor of my actual score.

Finally, you may ask: why is he advertising such a low score? Well - there's a good chance that residency programs already know my score. If you're reading this because Google brought you here, maybe you'll appreciate seeing a self-reported score that isn't in the 240 range. If you're reading this because your my friend, thanks for being my friend!

If you haven't taken the exam yet, hang in there. Take some time to focus on the material, practice with question sets, and try to take some time off to prepare. I wouldn't, for example, recommend studying at the same time as taking a required psychiatry clerkship.

Jump Into Sound

One of my patient's chief complaints today currently tops the list of titles for my first book, should I ever get to that point. The phrase carries multiple meanings ranging from dark to playful.

Jump Into Sound

What do you think?

Interviews

I've another article up at The Differential today. This one's about the anxiety associated with interviews. Not interviewing patients - interviewing at residency programs. Except that right now, my anxiety is centered on waiting for interview offers. For those playing along at home, I'll be updating a list (on the panel at right) of which cities you may be able to find me over the next few months. I'm linking the programs' websites, too (as much for my own utility as for your curiosity). Next week, I'll fly to the Bay Area for a month-long emergency medicine clerkship at San Francisco General Hospital.

Physician Heal Thyself

I've been a bit under the weather lately, and considering that I currently cannot see more than 50 feet out my window which can typically see mountains 50 miles away, that's saying something. Getting sick as a health provider adds conflict to the first directive of "do no harm" and lumps additional irony to the proverb, "Physician, heal thyself." Medical student status adds another wrench to the mix. I've written more over at The Differential.

Powell Endorses Obama

This entire segment on Meet the Press is worth watching, but I want to direct your attention to the part of his statement beginning at minute 4:27.



Right on, General Powell!

"What if he is?" and "Is there something wrong with a 7 year old Muslim-American kid who believes he or she could be President?"

These are the questions we SHOULD be talking about. And "Muslim-American" in that question should be interchangeable with atheist or agnostic or Hindu or Jewish...

2008 FOSEP Enegy Forum

In 2004, Seattle's Forum on Science Ethics and Policy (FOSEP) hosted an informational event about stem cells that attracted more than 700 people to the University of Washington Campus. This election year, a new group of graduate students has put together what promises to be even more timely. If you are in or near Seattle on Thursday, October 16, this event will be worth your time. Check out more at FOSEP's web site, or click on this poster for more information.

Take This Class

Click for a larger image. Email me with questions.

Clinical Skills

I am pleased to report that the United States Medical Licensing Examination has found me:

• capable of integrating a clinical encounter
• competent with communication and interpersonal skills and
• proficient with spoken English.

In sum, I passed the clinical skills portion of USMLE Step 2. Step 2 CS. The CS stands for Costly Sandwich. As in $1500. Or in my case, $500 each. For those outside of the medical education circle, this is the exam where senior medical students (or international medical graduates) fly to one of 5 American cities to take an 8 hour examination that consists of interviews with 12 standardized patient actors. The closest spot for me was in LA. The exam costs about $1200 not including lodging and airfare. There is a "free" lunch.

Register Today!

Have you registered to vote yet?

If not, today is your last day to do it if you want to vote in the most important election in my lifetime.

Rock the Vote has a really easy online registration in whichever state you're in.

Just Do It!

Going Crazy in the PES

Lately I've been thinking a lot about what the difference between psychiatric illness and normal variation. Admittedly, this is due to my frequent proximity to mental illness with my clinical rotations. My latest post to The Differential could blur the line a little more than usual. It's a must-read for my family and close friends. Can you figure me out?

Role Model

I'd someday like to be a Caleb Burhans of science, medicine and society. Don't know who that is? I didn't either until I read today's New York Times feature of him. Or, if you're oriented more to screen than print, watch this clip:



I found it an inspiring example of following one's interests and passions.

Carnivals!!!

My fellow bloggers,

Are you looking for some carnivals to showcase your best writing? Listen up!

Like so many of my extra-curricular interests, blogging has fallen a bit behind in the face of licensing board exams, finals, and long hospital work hours. It doesn't help that my current bus lines do not have wireless... But you've seen an increase here and at The Differential of late. I am really excited about what is going down over at Clashing Culture in the next two weeks. Thanks to the strong work one of my co-bloggers there (Mike, also known as Tangled Up In Blue Guy), Clashing Culture will be hosting not one, not two, but three carnivals in the next two weeks.

On deck over there is:

• October 8: Carnival of the Liberals ... Liberal politics hosted by Mike
• October 8: Four Stone Hearth ... Anthropology hosted by me
• October 15: Carnival of Evolution ... Evolution hosted by Mike
  

If you want to submit to any of these, click on the links above to either connect to a web form or to email the host.

it is finished

Step 2 Clinical Skills is in the rear view mirror, and I'm driving the speed limit. Which is only 55 on the freeway passing though my municipality.

Why only the speed limit? It's all those gruesome traumas I've seen in the ED were for folks driving ABOVE the limit...

Anyway.

I'm pretty sure I won't have to take the exam again.

Blame it on Congress

Before we all scream about how congress didn't pass a bill to give $7x10^11 to a bunch of fat cat bankers...

...don't forget about:

The bankers who lied to themselves.
And the loan applicants who lied to the lenders.
Oh! and the lenders who didn't care they were being lied to.

Boy, am I glad to be liquid!

Practice Question

A 30 year old colleague approaches you for a curbside consult. A friend of his who is 4 days status post a recent comprehensive psychiatry exam is now complaining of malaise, headache and frequent urination. He has rhinorrhea, and is complaining of frequent sneezing and a "throat tickle" that requires frequent clearing of his throat. He denies throat pain, ear pain, nausea or vomiting. Your colleague humored his friend with a brief physical exam. On exam, there were engorged nasal turbinates with profuse clear discharge, there was a mild white discoloration of pretonisilar pillars; tonsils were absent. His breath smelled faintly sweet. Bilateral mobile, tender, 3 cm sub-mandibular nodes were appreciated. Chest exam was clear. Further history revealed nocturnal urinary retention and dry mouth that awakens him several times at night. A thorough social history indicated the 'friend' felt a sense of impending doom, especially when presented with web-based tutorials. Your differential diagnosis includes:

A) Antihistamine use
B) Panic Disorder
C) Viral upper respiratory infection
D) USMLE Step 2 CK
E) Sleep disorder NOS
F) Caffeine dependence, sustained
G) Specific Phobia

Eloped

My latest article at The Differential is about the medical use of the word, "elope." It probably won't get as much interest and commenting as my last article about firing patients and abortion.

Some of the critical comments responding to my entry suggested it was inappropriate for me to draw similarities between firing psych patients because you cannot help them any more and referring patients to another provider if you are uncomfortable not performing a procedure (namely, abortion). At the core of my argument is my concern that patients get the best care available, and that they should seek said care from the best individual able to provide it. Most of the rest took the opportunity to voice their own opinions about abortion in medicine. Some of my critics argue that all doctors should be willing to provide abortions (that's not going to happen). One reader questioned my disclosure that I was 'uneasy' with providing abortions myself. I'm not sure how to respond to that... Finally, one reader has argued that we must get over the fact that the country is divided about abortion. I would argue that adopting this perspective would effectively invalidate half of your patients' beliefs.

500 Coyotes

Earlier this week around 6 AM, we caught a glimpse of a bushy black-tipped tail. And this evening, there was the familiar refrain of yip yaweeee. What a great way to celebrate my 500th post! The introspective coyote, searching for his reflection in pavement puddles is not a bad representation of the recent self examination I've been doing in the residency application process.

I'm guessing this season will have more rain and introspection. Hopefully, more coyotes too!

Happy 500 to me!

More than Meets the Eye.

I love living in a world where this is news.

When the transformer malfunctioned, operating temperatures rose from below 2 Kelvin to 4.5 Kelvin -- extraordinarily cold by most standards, but warmer than the normal operating temperature.

Isn't this so much better than what's her name's what's it called?

Controversy!

Abortion, psychiatry, firing patients: three issues that elicit strong emotions. So if you suffer from a panic disorder, you may not want to...

Read my latest entry at The Differential to get my take.

Otherwise, carry on!

ERAS

I just finished uploading my personal statement, applied to 30 emergency medicine programs and shelled out $365 to the Electronic Residency Application Service (ERAS). That's just one dollar a day to feed an orphaned... wait, that must be something else. I'm just glad I have the opportunity to continue my training to be a physician. Since my wife and I are both applying, we have selected ten cities that have programs that appeal to both of us. They include (from west to east):

The Bay Area
St. Louis
Chicago
Atlanta
Pittsburgh
DC/Baltimore
Philadelphia
New York
New Haven
Boston

This is the end of one stressful task (applying), and the beginning of another (hopefully, interviewing!). Read my personal statement here.

Palin, The Alaskan

My favorite local editorial cartoonist points out that just because you're from Alaska, doesn't mean you have the interests of wilderness in mind. And by one perspective, it's likely that your idea of custodianship is more akin to pillaging. We Washingtonians have an interesting relationship with Alaska politics: we're big trading partners, AK is a frequent vacation destination, most of the fishing fleet docks in Seattle's Ballard neighborhood, we share a medical school - okay that last one's not SO big a deal... This is the third or fourth consecutive shot at Go. Palin that Horsey has taken this week. I guess it's one way we look out for or meddle in the business of our neighbor to the north.

Me, In A Page

Lately, I've been diverting most of my wordsmithing to a one page document that may be the single determinant of where I spend the next four years of my life. Putting these ideas about science, medicine and society into a page has me really excited about a career in emergency medicine.

*****

One late summer night in Harborview Medical Center's emergency department, an exasperated medicine resident turned to me with a rhetorical question: “Who would want to treat homeless, drug-using prostitutes?” When I immediately thought, “I do,” I knew I was home. This epiphany at the end of a month in Seattle’s level one trauma center cemented my commitment to a career in emergency medicine. Contributing to the trauma team, working with a diversity of cases, the rapid progression from presentation to diagnosis to treatment, and the societal issues I pondered after each shift all conspired to entrench my connection to the ED.

My path to a career caring for the acutely ill started with dreams of building life support machines. As a clinical technician for the University of Pittsburgh's artificial heart program, I learned that invention and patient care have a tendency to interdigitate. The image of science and medicine clasping hands framed my motivation for earning a bioengineering PhD. I developed innovative new surgical, molecular and tissue engineering techniques as part of my thesis project to improve the viability of embryonic stem cell-derived cardiac tissue replacements for use after myocardial infarction. Long hours in the lab doing thoracotomies on mice and measuring with echocardiography the extent to which we were repairing infarctions introduced me to the importance of intellectual and manual dexterity in medicine. Experience suturing hundreds of rodents enabled me to consider each human laceration repair a new artistic challenge. My first successful ultrasound-guided basilic vein cannulation opened wide my appreciation for sonography in the ED. Emergency medicine requires mastery of numerous techniques and knowledge from many disciplines; this environment of collaborative innovation makes EM a perfect career for someone like me who wants to combine multiple skills and interests to provide the best care for patients.

The notion that today’s scholars have to focus narrowly on subdivided fields in order to make contributions to society contrasts with my perspective that the actors of social change must think deeply in multiple fields. As a graduate student working with human embryonic stem cells, I learned firsthand not only how scientific research occurs in the context of social and political concerns, but also that scientists and physicians are obligated to contribute to public dialogue. I am as proud of defining 'blastocyst' and 'in vitro fertilization' for stem cell research legislation in Washington State as I am of my labwork to further the potential of cardiac regeneration. Through a science policy group I co-founded, I planned campus-wide conversations about genetically modified food that spurred constructive conversations that continue more than three years later. Hosting President Clinton's science advisor to engage the University of Washington about the future of research funding in America offered a glimpse into the importance of sound science policy.

However, one needs look no further than county hospitals' waiting rooms to see that innovation in patient care is not merely a scientific enterprise – it needs to be a social one. Our current policy morass of underserved health care in America establishes emergency medicine as the front line for individuals seeking to heal people and the system. Solutions are not easy to find, especially from within the academic ivory tower; some of my understanding of the complexities of urban health care is grounded in relationships I've built over four years as an STD counselor for homeless teens. I aspire to be the emergency physician who draws on experience treating the neediest of patients to facilitate difficult conversations about health policy.

The ED is not merely a safety net. Challenging ethical dilemmas that emerge from a diversity of diseases, the urgent presentation of humanity in crisis, and the varied manner in which people respond to acute illness demand that emergency providers have ethical reasoning skills at the ready. The emergency room is a laboratory for teaching medical ethics; I hope to translate an “Ethics in the ER” course I developed for medical students at the University of Washington into a training tool for tomorrow's doctors. My experience designing this course has helped me understand better that educating others is a critical element of the practice of medicine. Teaching forces me to shore up topical understanding and requires communication accessible to a range of individuals: patients, students and colleagues. I look forward to an EM residency that provides both teaching role models and opportunities to refine my own skills.

Scientist, activist, writer, ethicist, engineer, doctor: for me, each of these roles supports the others. Rather than a collection of titles in separate contexts, I prefer the simple title of citizen-physician. There is deep meaning in the patient-physician interaction, both in the literal space of a sick person seeking care and as a metaphor for how physicians can improve society. My diverse and well-developed interests are ingredients for a career in emergency medicine that steps beyond discrete disciplines to address patients’ immediate health needs and improve the practice of medicine.

Where'd I go?

Long Story Short:

My computer crashed and I've been busy studying for Step 2 of the medical board exam in the midst of a rather busy psychiatry service.

I'm still working on recovering everything from my old (Windows) lappy. Once that is done, I'll be more happy. Yes - that rhyme was sappy.

But at least I'm back.

Psyche Me In!

Just a brief update:

I finished the third day of my psychiatry clerkship this evening. The patients my team cares for are on the lowest acuity section of the floor, but that means there are a lot of interesting - and sad - personality disorders (versus the floridly psychotic). The learning curve is steep, but I think I'll get a basic hang of the topics in a few weeks. What I am really excited about is honing my interview skills. This is the perfect place for that.

Big News!

One of the things that has been keeping me from posting new entries here is a little project I've been working on for the past 4 or 5 months. Today, I received an email from the chair of UW's Medical History and Ethics department that opened with,

We are happy to endorse the plan for an ER Ethics course as you outline it, and look forward to providing it as an MHE offering.

Whoop Whoop!

I mean, "My, what a fine outcome. I cannot wait to see this effort come to full fruition." Or something.

The bottom line is that back in March, I was in the emergency department admitting a patient to the medicine floor when I ran into an emergency attending who I knew as a sophomore medical student back in what they call the day. We knew each other to be writers, so we caught up about each others' activities. She told me about a cool medical humanities 'zine she was writing a proposal for (since funded!). I told her about my gig at The Differential. And she mentioned an idea for teaching an ethics class based on cases from the ER.

Schreech!!! My mind and body did a double take.

I don't exactly recall what condition the patient I was admitting had, so will take some narrative privilege (and play the statistics) to report that I thought: "the guy with hepatic encephalopathy can wait a few more minutes." In truth, it was 3AM, we had already examined him and written orders and I was checking lab results in the fishbowl (which we call the central command center of the ER) before getting a couple hours of sleep. As usual, sleep takes the back seat.

The bottom line is that sleep was sacrificed for this project more than once. The opportunity to apply what has always been an extra-curricular (or at best co-curricular) interest in ethics to my chosen profession was amazing. As the chips lie today, this winter I'll be co-teaching (with the emergency medicine attending) a class to first through fourth year medical students called "Ethics in the ER." The curriculum is discussion oriented, is based on numerous actual cases, will employ a blog/discussion board and require a small amount of reading from medical humanities and ethics sources.

I think the curriculum we're developing is a unique approach in medical ethics education, and are excited about testing it and reporting our experiences for others to learn from and improve. I am also looking forward to a few more energized late nights turning theory into practice.

Getting By On Metaphor

I take my metaphor extended, not mixed. Need proof? Read my latest post at The Differential. It's about the residency application and interview process. I'm only at the opening round of the process, and I've already had to lean on allegory. If John Bunyan were a senior medical student, I think he'd approve.

I am only slightly comforted by the fact that my understanding metaphor rules out certain psychiatric diseases. Today was day one of my psychiatry clerkship, and I've already determined that I'm one major depressive episode away from a Bipolar Type II. (Anyone who knows me can appreciate the hypomania I've experienced over the years. I guess I'll just have to settle for cyclothymia. And as my psych attending pointed out today, people don't get admitted for cyclothymia - it's just to close to normal!

By the way, look for additional self diagnoses in the next 6-10 weeks. I hear it's pretty common on the psychiatry clerkship!

The HIPAA in the Room

I've been a little gun-shy of my posts on Hope for Pandora recently. It seems as though a Seattle medical version of big brother may be watching... watching blogs. One of my friends - a blogging friend and real-life friend - was asked to remove material or shut his blog down because a compliance officer at a hospital where we train was concerned that certain of his posts violated patient confidentiality. Check out Noel's blog, aptly named, Constructive Procrastination.

I have sought to maintain the integrity of my writing by anonymizing my stories or asking permission of my patients to write about them or folding several patients into one pseudo-fictional account in the interest of telling a good story. Each of these techniques fall within the guidelines of the Healthcare Blogger Code of Ethics. What bothers me is that my friend had also observed these behaviors in his writing.

What bothers him is the manner in which he was approached. I'll let him tell the story in his own words, which started a couple of weeks ago. It seems as though our hospital wants to have more control over what gets into the public domain from experiences inside the hospital. Since I have vague aspiration to publish some of my own expereinces in a format more commercial than a blog, this got my ears up. After all, I already write for lunch money over at The Differential. I contacted folks in the community relations department before starting that gig - I wonder if someone else is trying to enforce some element of control or oversight on writers like me.

I think that my hospital administration is a little out of its league right now. One in ten Americans have tried their hand at blogging or something like it. I'm betting that health professionals are no exemption to that. I'm a little worried about an Orwellian move here. Why isn't the Health Care Blogger Code of Ethics or something like it good enough?

The compliance office may be full of friendly faces and good intentions, but do they really know what they are trying to do? Fortunately, my friend has volunteered to provide a voice for us bloggers.

Facebook Pages

Here's a little entry to bring the blogosphere and the facebookosphere (?) a little closer together.


I've recently joined some Facebook groups that some of my readers may be interested in:

1. The American College of Emergency Physicians (ACEP), where I've started a little thread about ethics in emergency medicine.
2. The American Scientific Affiliation - a group of Scientists who are Christians... all perspectives are welcome - even extreme ones - but most of us seek paths that makes the two fully compatible.
   
3. The Student and Early Career Network of the ASA... there isn't a lot of support for younger Christians who are scientists. Perhaps this group could help with that.
4. Science Bloggers. Yeah, I think I am one of those.

Oh, and if you want to be my Facebook friend, drop me a note.

Seven Years

August 9, 2001: A day that will live in infamy. (Among stem cell researchers, at least.)

That's when President Bush announced his policy regarding human embryonic stem cell research.

In remembrance of this day, I wrote up my thoughts at the seven year point over at Clashing Culture. In a way, I am glad Bush made that speech. I probably would not have gotten so invested in science policy and the public communication of science, may not have involved myself with FOSEP, and would not have developed a self-conception of myself as a citizen-scholar.

Whoa...

Sovereign

Hopefully you've noticed that some battles between countries are not merely figurative (as in Beijing right now). As war breaks out between the small republic of Georgia and its enormous neighbor, one cannot help to recall parallels with previous conflicts between a superpower and a thorn in the side. And if you've any confusion about what I'm referring to, consider this snippet (made in Beijing, where the speaker had just eaten lunch with Russia's president):

“Georgia is a sovereign nation, and its territorial integrity must be respected,” Mr. Bush said in a hastily arranged appearance at his hotel. “We have urged an immediate halt to the violence and a stand down by all troops. We call for the end of the Russian bombings.”

It seems to me (in my simple mind) that Russia's just taking a lesson from the good ole U S of A. I would like to see the above quotation replace 'Russia' with 'America' and 'Georgia' with 'Iraq.' but that's just me.

With a Little Help From Your Friends

My latest article for Medscape's The Differential includes some tips about how to make the most of the teaching you'll encounter on your clinical rotations. If you listen closely, you'll encounter help from people all around you. Even from the gruffest nurses and most militaristic scrub techs. Check it out.

Podcast From the ASA Meeting

The talk I gave last weekend at the annual meeting of the American Scientific Affiliation about blogging as a useful tool for talking about ethics, science and religion in the classroom and in the public sphere is online. Listen to it here. It features my motivations for blogging, my experience here and at Clashing Culture, and some ideas about how blogs could play a larger role in dialogue about science and society in the public and within the mission of the ASA.

Man, is it painful to listen to yourself. Follow the link to the audio file at your own risk. I'll figure out how to post my slides, too.

I did talk a little about PZ Myers and Pharyngula as an example of discussions about religion that are more one-sided than I like. What did not come across until late in the discussion was how PZ linking my page once was a great boost to my activities on the web. For his notice and the associated traffic it brought I am thankful.

I did meet some other bloggers at the conference. One of whom lives about two miles from me.

Don't worry! There will be plenty of responses to the meeting coming up, mostly at Clashing Culture. See you there!

In LA for an Exam

I'm typing this entry from a hotel in Los Angeles. A few days ago I was in Portland for a conference about issues in science and Christianity - more on that later.

Tomorrow I take an 8 hour clinical skills exam in which I interview (and am evaluated by) standardized patients who act as though they have diseases. For this opportunity to demonstrate my bedside manner and English proficiency, I get to pay about $1500. I'm sure I'll have more to say about that. My wife and I are taking the test at the same time, so at least we can split the hotel room!

We went for a walk around the neighborhood tonight - the test center is just across the street from a Raytheon plant. Yes, the same Raytheon that makes bombs and missiles. And there's a huge oil refinery in the other direction. Awesome...

Carnivals!

Hey You!

Go check out two recent blog carnivals that I happen to have entries featured in. There's a moving collection of "Why I'm in medicine" posts at the Grand Rounds hosted by Edwin Leap, and my Differential colleague, Ben Ferguson assembled and reviewed a great collection of cancer articles at nosugrefneb.

Code-I-fied

I am now certified by the American Heart Association to run a code.

Should someone stop breathing, drop her heart rate below 50, pass out, develop hypothermia, have a stroke, elevate his heart rate to more than 150 at rest, have a heart attack, not have a pulse, or otherwise become unresponsive, I have the requisite knowledge, practice and peace of mind to direct complete life saving measures. In other words, I am ACLS certified.

This does not apply to kids or to individuals who arrive at a compromised state because of trauma. Even so, it's pretty amazing.

And to think four weeks ago I was arguing my case about an unfair grade.

One more night shift for me, then a weekend conference in Portland, than an oral clinical examination in Los Angeles, then...

...back to regular blogging!

Typing My Way Through

I've been typing my way through the dark hours in an effort to maintain the night schedule I'm currently assigned to on my emergency medicine clerkship. Only six shifts remain in this 4 week marathon sprint through emergency medicine. My lists from the ER have grown long with procedures learned, diseases treated, and stories both of pain and resilience. This evening I've bounced between editing my residency application's personal statement, that left-over of a paper from grad school that just can't seem to make its way into print, blog posts here and elsewhere, a presentation about blogging in the public sphere for a meeting of the American Scientific Affiliation, and a few case studies for an ethics class I hope to help teach in the Winter quarter. Typing my way through the night, indeed!


As the morning dusk transitions into the early hues of dawn, I realize that there's more than just productive work going on here. Sunrise has always inspired reflection in me. Context is an important historical factor here: 2 AM weariness has been reliably rewarded with 5 AM ebullience secondary to completing a project or assignment; early rising is often associated with an exciting day's activity; waking up with the sun reminds me of fond camping memories.

Today seems different to me, however. The sun is rising on my day in the context of deliberate introspection. Whether it be blogging recent experiences in the emergency room or dissecting (massacring?) the one-page personal statement, tonight prepped me to reflect on more than just why I do medicine. Why do I write? Why do I love? Why teach? Why make art? Why work so hard?

Maybe it's that built-in ecstasy of the morning, but today the answers to each of these for me is all so clear. And I think it's the same for many people, and especially health care workers.

I seek to make a difference.

In family life. In students' learning. In patients' health. In my own health. In my community. In...

Sure, there are other subtle or specific reasons for doing the things I do, and other large parallel motivations exist for how I carry on and prioritize my activities. My personal faith, for example is a dominating motivator and inspiration for me.

My "a-ha" this morning was due to my realization that each of the major pillars of my sense of self is linked to the other. I write to help myself through the trials of medicine or love. I teach to build understanding - in myself and others - of the interrelation of the human condition through art, science and medicine. Medicine helps inform my writing, teaching, and how I love friends, family and fellow man. I work to fill in gaps that will always persist - in my own understanding, between rich and poor, and between sickness and health.

All of this is too vague and flowery for a personal statement, but nothing's off limits for blogs, right? When it comes down to it, I'm training to be a doctor because I love. Walking along side people for a little while in times when they need help doesn't sound so bad to me as a profession. But balancing self-care and care for others is a trick for anyone invested in others' personal lives. For me, it's a lot easier when the facets of life are tied to central principles.

Interconnectivity of personal purpose has worked for me. Is there a reason I do this or that? For me, the answer is yes even though I'm be able to put my finger on it at the time. For example, I started blogging in the dark days (they usually hit around the third year) of graduate school; writing generated in me a greater comprehension of calling. If only because it was so helpful then, you can expect to find me typing my way through future joys and struggles as well.

And now, I must go wake my wife. My goodnight kiss is her good morning. Today, I'm an alarm clock, too.

Blogging My Needle Stick

Taking my lead from ScienceBloggers Abel, who blogged his vasectomy, Dr. Free-Ride, who blogged her mammogram, or Zuska, who blogged her dilation and curettage, I decided to blog a recent personal medical experience of my own: a dirty needle stick.

Working in the Harborview emergency room is a unique experience. Medical students have the unique opportunity to be 'doctor' for a large number of patients. Yes, we have supervision... but if a case is straight-forward, we are permitted, correction, expected to manage the patients' care from start to finish. Students also see a large number of complex cases. Typical large hospitals may see 4 or 5 traumas roll through the door in a day. Regional trauma centers like Harborview commonly receive 50 medivac, airlift or medic arrivals each day. Medical students only manage the most simple of these cases, and even then, it's under the close eye of two residents and an attending physician.

It was in one of these cases that I incurred my first dirty needle stick.

Before this time, I'd never actually stuck myself with a needle. Five hundred rodent thoracotomies and a year in medical school, and never once had I punctured my skin with a suture or injection needle. My clean streak ended in the Harborview ER.

We received a morning transfer from a hospital in Montana. The announcement had come in over intercom that an intubated young man with a gunshot wound to the face was in transit. Only the basics are conveyed in these announcements, the dispatch only relays information critical to receiving the patient and supporting him. Often, GSWs (as they are referred to on the patient board) come with no warning. Rooms are already equipped to handle victims' emergent needs. By the time that "Airlift is through the door" was announced, I was in the room ready to help with the case.

My extensive (for a medical student) experience with delicate surgeries comes in handy in the trauma bays. I am happy to suture head and hand lacerations for the busy residents, and I take pride in my skillful artistry. (Although, I am careful not to tell patients where I got all of my experience.) By some miracle, the large gage bullet missed the jugular vein and carotid artery. It had destroyed most of the right half of the jaw and torn open the neck below where the angle of the jaw had been. Without major vessel damage, it was clear that some temporary repair would be performed before the patient went to the operating room; I made sure I was in the right place to help. By the time the ear nose and throat (ENT) surgeon came down to the ER, I had washed the wound with five liters of warm sterile saline. The surgeon was a young resident. At the time, I made no notice - owing to my extra-medical education, most of the residents are younger than I am. But this guy might fly in the face of a previous argument I made in the debate over whether it's more dangerous to get sick in July than any other month.

In the hierarchy of medicine, there is one way to make suggestions to superiors that helps get around the delicacy of status. It's the "would you like me to" question. Medical students and residents should always pay attention to the friendly nurse who asks, "would you like me to send this blood for lactate and enzymes, too?" or the physician's assistant who asks "would you like me to sign an order for labetasol? I've had good success turning this into a nice approach to suggest we do something with minimal toe steppage. In this case, I asked:

• Would you like me to make a sterile field around the wound?
• What size gloves do you wear?
• What do you think about clamping this small artery? and
• Would you like me to move the sharps off your field?

I'm pretty sure I asked that last question immediately before I felt a sharp twinge in my left ring finger. The resident had put down an old needle in a rather precarious spot, and I thought, "he's going to stick himself with that when he reaches for his forceps." I grabbed the remaining stub of thread from the field, careful not to let the dangling hook catch my glove while he took a sweeping pull at the current suture on his first knot. Ouch! Quick inspection showed the cutting needle had caused a rent in my glove and that my blood was mingling with the patient's. I immediately left the sterile field, washed my hand with soap, all the while milking the wound like a blood drive phlebotomist checking your hemoglobin. My hand was in the wrong place at the wrong time.

At my hospital, one employee per day experiences a needle stick. It is so common among health care providers that there are highly standardized approaches to dealing with the experience. The first steps occur in the ER. Fortunately for me, I was already there and everyone I came in contact with worked in an efficient manner. Along with the compassionate first year surgery resident who later that day asked if I wanted to talk about my experience, or the attending who checked in by email several days later, the efficiency of the process counter-balance my building worry with a sense of support. None of them knew that my wife was on vacation out of the country and that I might not have anyone at home to talk about this with. They were just there.

So what is the risk of needle stick injuries in contracting blood-borne diseases? My reading suggests the average risk for HIV transmission after percutaneous exposure to infected blood is low - about 3 per 1,000 injuries. And that is with exposure to infected blood. The other killers to worry about are the hepatitis B and C injuries, and they have much greater transmission rates. Transmission in needle sticks with exposure to the hepatitis B virus is 30% and could be as high as 10% for the hepatitis C virus. Like all health care workers, I am immunized against Hep B. There are a host of other diseases transmissible by blood (see this nice Canadian site for more info), but I was most worried about Hep C and HIV. There are no cures or vaccines for these diseases, but there are decent treatments for them. In particular, immediate use of anti-retroviral drugs have good evidence of reducing transmission from needle sticks. But did I want to take them? This returns me to the specifics of my situation. Much of medicine is paying attention to the history; this case's history is obscured because the patient was intubated and communicating via hand squeezes, and that his family was still en route.

The patient was a young man from rural Montana. Epidemiologically, that cuts his risk of having HIV or Hep C. But why was he shot? The story at the time was that he was snooping around a hermit's shack at 2:00 in the morning. My hunch was that illegal behavior was involved. Fair or not, at the time, this element increased my perceived risk of his being seropositive. In my head, I quickly came to the conclusion that my chances of catching one of the big three were very small, but not non-existent. I made the quick decision to take a dose of Truvada.

Whenever there is a dirty needle stick, the potential donor's and the stuck person's blood are sent for testing. This information is used both to treat or reassure the stuck employee and to establish a record of serotype. Usually the patient who's blood contaminated the needle must give consent for the tests, but in the case of an unaccompanied unresponsive patient, this makes matters more difficult. So my blood was sent, and eventually his was. (By the way, this information is divorced from the patient's or my medical record, for both confidentiality and billing purposes.) When the rapid antibody-based HIV test returned negative, I was comforted, but not quite enough to stop taking the anti-retrovirals. Anyone who's taken or given an HIV test should know about the "window period." This is the time it takes for the immune system to seroconvert: it's the interval between infection and a measurable level of antibodies in the blood. For HIV, this is about 6 weeks, but many still use 3 months as a fallback number. The antibody test can therefore only tell you the HIV status of a person three months ago. There's another, more expensive test that measures the virus rather than the human antibody to the virus. It uses genetic amplification to look for viral genetic markers. This can both reveal virus before antibodies are formed and tell physicians how much virus is in the blood (and therefore, more about the patient's symptoms and disease progression). I decided to request this test. After all, if this young man recently took to exploring hermits' shacks, what's to say he hasn't experimented with new drugs or sexual practices?

This argument was barely enough to convince the employee health director to proceed with the genetic test on the patient's blood and required me to take two more days of the one-a-day emtricitabine/tenofovir combo drug. After several conversations opening with my telling her my mother's maiden name, I learned that my serologies and the patient's were all consistent with no infections or infectivity. By then the stress of this experience had faded into just another experience in the Harborview ER. I'll probably be stuck again, and next time, probably won't seek the viral PCR test. But will I take the anti-retroviral immediately after the exposure? You betcha! With no side effects and once a day treatment, the only reservation is cost. I don't know how much one Truvada pill costs because my hospital paid for it. By the time the next stick occurs, the state of diagnosis and prophylaxis for HIV and Hep C may have changed. Perhaps there will even be vaccines.

Perhaps.