Thursday, July 31, 2008


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!

Friday, July 25, 2008

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.


Thursday, July 24, 2008

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.

Monday, July 21, 2008

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!

Thursday, July 17, 2008

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.

The Internets

The internets are back at my house!

After almost 3 weeks without the line, we now have connectivity.

You'll see a few more posts from me here and elsewhere, but not many, owing to the insane schedule I've been keeping.


Saturday, July 12, 2008

Shift Work

I was amazed to learn that in one month, a full-time emergency medicine physician works about 10 shifts of 8-12 hours each. That hardly seems fitting for a 6-digit salary.

After four back-to-back 12 hour shifts at Seattle's Level 1 trauma center, I think I understand what's going on here. Half a week at Harborview's ER kicked the crap out of me! Here are some relevant random statistics from my four day marathon:
  • 1 showdown of thumb vs. nail
  • 11 IV placements (15 attempts)
  • 3 rectal exams
  • 10 hours on Metro buses
  • 7 rainbow series (fresh sticks, not from IV access)
  • 17 log rolls
  • 2.5: number of hours extra I slept on my day off
  • 4 admissions
  • 13 hot dogs eaten
  • 3: number of times I checked my email
  • 1 shoulder reduction
  • 1 patient departure against medical advice
  • 5 assaults
  • 2 codes
  • 8 pounds lost
  • 4 drug seekers
  • 1 call to a friend for moral support
  • 5 mistakes (that I know of)
  • 0 patients signed-out
  • 2 injured firemen
  • 3 interpreters
  • 2 times I wished I could go home
  • 5 times I wished I was still at the hospital
  • 21 clothing fibers removed from wounds
  • 5 digital nerve blocks
  • 2 abscesses drained
  • 3 patients seen on the street after I treated them
  • 10 minutes: the amount of time I felt in control
  • 4 injuries involving balls
  • 2 radial artery blood gas samples
  • 2700 calories eaten per day (approximate)
  • 5 different running lists of what I've experienced
Shifts in the ER are tiring. And I was the primary caregiver only for 'simple' patients, doing 'easy' procedures. (We participate in trauma arrivals.) On my feet for 12 hours, forgetting to eat, drink, pee... I suppose that getting used to this environment will involve better control and awareness of bodily needs. In the mean time, I've got some reading to do. 14 more shifts for me this month.

By the way, others are currently blogging about time in the Harborview ED. Check out Constructive Procrastination. Noel is my diametric opposite in terms of shifts: he is medicine nights and I am surgery days. That doesn't keep us from feeling some of the same things about the rotation.

A Big Burly Joke

A few weeks ago, I came up with what I thought was a great riddle. After none of my hand-picked readers figured it out, my wife suggested I rephrase it in the form of a joke. One intrepid reader offered a good guess (Burl Ives Trio) that was not what I was looking for.

So for those of you reading this for the first time, here is an (improved?) version of the joke:

A surgeon, a pathologist and an oncologist are hiking through forest when they encounter a burly tree (shown at left). Curious by nature, they sit down to ponder their discovery. Of course, the surgeon proposes to cut open one burl. The pathologist thinks that's a good idea; she whips out her pocket microscope to examine it. The oncologist goes on about a two-hit hypothesis and proposes dumping toxic chemicals onto the tree's base. What do you call this conclave of MDs which also happens to be a name for the piece of wood being examined by the pathologist?

A Tumor Board!

I tried to tell this riddle/joke at a recent party I held at my house when I realized that a few years ago, I had actually sliced up a small burl with the intent to make a set of coasters out of them. (The slices warped, and will need additional work to make them functional.) I got some laughs, but not because of the joke. Mostly, my guests thought something about the back-story was hilarious.

This group of mostly medical professionals proceeded to hypothesize the origins of burls. We all decided burls are some sort of tumor. Perhaps it's caused by a genetic cancer, but also perhaps by insects, fungus or viral disease. (Viruses cause tumors in humans, too!) That burls often congregate in groves could support a genetic or infectious cause. But the tendency for burls to form on golf courses and orchards speaks to a traumatic origin. Maybe the burls I saw in Alaska are residual from moose antler scraping behaviors or aborted assaults by beaver?

For those out there who have never heard of the second meaning of "tumor board," you will probably not think this as funny as I did (and still do, by the way). At most hospitals, there is a special meeting of specialists every week that serves to discuss the new, complex or complicated cancer diagnoses. Since every cancer is a little bit different, and every patient is different, you can imagine there could be a very large number of approaches to cancer therapy. In an effort to provide the best care, pathologists (who have the final word on diagnosis), surgeons (who provide the important skills to remove some tumors) and oncologists (typically the doctor in most contact with the patient) all meet to present and deliberate information. This meeting is called a tumor board.

July is the Cruelest Month

Have you heard the medical maxim that you shouldn't get sick in July because that's when new residents take over in training hospitals?
I take issue with this perspective over at Medscape's student blog, The Differential. Check it out.

Saturday, July 05, 2008

Back Home

My past two weeks included travel to locations that were either the furthest north I have ever been or the furthest south. I left Fairbanks, Alaska on a Wednesday, took an exam in Seattle on a Friday, then flew for a vacation in Ixtapa and Zihuatenejo on Monday. That expanded my latitude latitude by 9.5° north and 1.5° south for an expansion of 11°

Fairbanks: 64° 50' 16" N
Zihuatenejo: 17° 37' 59" N

Previous North: Northern Ireland 55° 10' 0" N
Previous South: Hawaii (Big Island) 19° 3' 51" N

Anyway, I'm back home and studying in preparation for my emergency medicine rotation at Seattle's county hospital and trauma center: Harborview Medical Center. I'm also getting a bunch of entries ready for posting here, at Clashing Culture and at The Differential. Now all I need is to finish setting up internet at home!

Want to figure out the latitudes and longitudes for city places? I found this website helpful.