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.

Market Research

Hi there,

Every so often it's nice to hear from regular readers. Toward that end, DrugMonkey threw out a meme that I thought was worth a try. But instead of posting something on your own blog, all you have to do is post an anonymous (or nominous, I guess) comment. If you read regularly and I don't know about it, it would be nice to hear a little bit about who you are. These days, I think most of my readers come in via google searches because I am not putting much content out, what with my insane schedule. Anyway, here's your charge dear reader:

Tell me about you. Who are you? Do you have a background in science or medicine? If so, what draws you here as opposed to meatier, more academic fare? And if not, what brought you here and why have you stayed?

Have a nice day.

Drug Seekers

We see a lot of folks looking for pain meds in the ER. I collected some thoughts in a piece at The Differential that you may be interested in reading.
My hectic schedule precludes me from writing around here these days. After my county hospital ER experience, I'll be back! I'm taking notes (on regular paper!) about entries for later.

The Switch

The emergency room is open for 24 hours. And the bigger ones are busy the whole time. A career in emergency medicine requires the ability to work at odd hours. Not long hours - 'full time' in many big ERs could be ten 8-12 hour shifts a month - but odd ones. Who wants to work the 10P to 6A shift every time? As such, ER docs must learn to sleep at any hour and work at any hour. The same applies to medical students. My emergency medicine rotation is 4 weeks long. Students spend two weeks on a day shift and then two weeks on nights. In 90 minutes I start my first night shift.

"The switch" as some call it is tough; there's probably a reason humans evolved with circadian rhythms. (I wonder what's been done in the evolution and development field on that!) I tried a couple of adaptation techniques. Who knows if they will help me to be alert tonight. So far, I:

• Worked an extra shift (Saturday night after a day shift, for a total of about 22 hours) I figured this would make me tired enough to sleep through the days. But then I didn't work Sunday night... And it was impossible to stay awake at home.
• Slept whenever I felt like it... naps here and there - atleast 90 mins to increase the likelyhood of getting a full sleep cycle in.
• Rested when I was awake: reading, writing, watching a movie. Nothing that would make my body tired.
• Took some benedryl around noon. I wasn't sure I would get any napping in, so wanted to seal the deal. It's a pretty good sleep aid for me.
• Abstained from caffeine. I think it works well for me in regular intervals, and maybe if I have a can of DMD on my way in tonight, that will help me get back on track.

I think I'mm rested enough to make it through tonight's shift and tomorrow morning's 8AM class. But I've got to get a little more regular if I'm going to last for 2 weeks!

Three More Shifts

I've the day off today! For those of you reading for updates from my time in medical school, here's another bullet list. It's not as comprehensive as the last one, but still gives a picture. I'll have more substantive entries later, but I must finish my residency personal statement and the paper resubmission today. Here's an abridged sum list from my most recent three shifts:

• 1400: estimated calories consumed, per day
• 1 femoral stick for blood gasses
  
• 21 smelly socks removed
  
• 2 trauma patients under my care (As in my name was on the board as the doc, but several people were helping me/watching my back as I was placing the orders)
• 1 advanced directive conversation
• 2 cases of gout
• 207/156: BP of one of the gout patients
• 6 cans of Mountain Dew consumed
  
• 1 needle stick
• 2 doses of Truvada taken
• 6 different bus routes ridden
  
• 5 IV's placed in one day (my highest count)
• 1 thoracotomy in the ER (observed, only!)
• 2 severed fingers
• 7 consultations with social work
  

Some of these could take up entire posts, or series of posts. But really, I have work to do!

Mistakes in Medicine

Rarely a day goes by in the medical student's day without him making a mistake. Some are more grievous than others. Yesterday, for example, I lost my clipboard for about 45 minutes. Fortunately, I only was looking for it for 10.

Anyway, early in my emergency medicine rotation, I made a mistake that is one from the category, "to learn from."
Then I wrote a little about my experience over at The Differential. Go there to read it.