Sunday, July 03, 2005
  Happy July 4th!!
Just wanted to wish everyone a wonderful July 4th. Be careful. If your town is anything like mine, things started to get crazy early. Watch out for the nut-jobs driving around looking skyward rather than on the road ahead. And please, don't be one of the nut-jobs.

I start my first "official" 4th year rotation tomorrow - Anesthesiology. Should be fun, and I should learn alot.
Thursday, June 02, 2005
  Opening up AOA programs
I'm about to mention something considered faux-pas in the osteopathic community: Opening up AOA residency programs to allopathic physicians.

Since the mid 20th century, osteopathic and allopathic physicians have been training in parallel - allopaths go to school in LCME-accredited medical schools and train at ACGME accredited residencies, osteopaths go to AOA accredited medical schools and train in AOA accredited residencies. However, in recent years, more and more osteopathic students have fled to ACGME training institutions. Something like 50% of osteopathic medical students matched into ACGME residencies in the 2005 match, leaving the other 50% in AOA programs.

There are many arguments as to why this is so: Many students quote their desire to escape the clutches of the "dogmatic" AOA. Others mention more practical reasons - hospital size, patient volume, location, perceived superiority of training at ACGME residencies, or increased opportunity for fellowship training. Whatever the reason, the AOA (and AOA accredited postgraduate training institutions) have been left with the reality that students are not applying to, nor matching at, their training programs. This has left many hospitals in a pinch, and the AOA wondering what the hell happened - while they were busy trying to push a superfluous exam and convince every student that a change in the initials after their name would make them more "osteopathic," they seem to have lost their audience. Every year, over 3000 osteopathic students graduate, and nearly 50 per cent do not match into their own postgraduate training programs. This should send a blaring message to the AOA that they are doing something horribly, horribly wrong. Unfortunately for us all, they have not been listening. They only seem to blame the medical students, rather than their own poorly designed system for the exodus that has occurred in recent years.

Many reforms must be made to osteopathic postgraduate education: better teaching, more volume, more consistency between programs. As it stands now, there are a few high-quality training programs, and many more low-to-poor quality training programs. This situation leaves the medical student in a hard place - face professional exile from their accrediting body or complete poor training. No surprise many students are choosing the former.

In recent years, there has been a huge push from the osteopathic student body for a combined AOA-ACGME match. The AOA (in true AOA-form) is firmly set against the proposition, fearing that a combined match (rather than the high-pressure roulette system they have in place now) will lead to more students abandoning osteopathic residencies in favor of ACGME training programs. I understand their argument, even if I do not agree with it. They are afraid osteopathic GME will cease to exist if the doors are opened for osteopathic medical students to enter ACGME programs without fear of excommunication. I don't see how this is necessarily a bad thing. The good programs will stay, the poor programs will die off - as well they should. Competition is only good for the system.

One of the complaints I have seen from allopathic students is something to the effect of, "why should we support a joint match when we won't get any benefit from it?" As it stands now, AOA GME programs only allow DO students to matriculate, meaning that allopathic students cannot enter into osteopathic residency programs. Allopathic residency programs are more "open" (for the most part), allowing DOs, USMDs, IMGs, and FMGs to apply and train at their programs.

What I am proposing, is for osteopathic GME to reciprocate and allow any and all-comers to apply and match at their programs (in conjunction with a combined match system). This would serve several purposes. First, it would provide those allopathic students interested in osteopathy the opportunity to train in a program where OMT and other osteopathic modalities are emphasized. It would also eliminate the inequities in the current combined-match scenario. It would enable those programs the opportunity to stay open, since the pool of potential applicants would increase roughly 400% or more. Another benefit would be increased exposure to and acceptance of osteopathy, since MDs training in osteopathic postgraduate medical institutions would be less likely to slight the profession than those with no exposure and only hear-say upon which to base their opinions.

I'll be adding more to this at a later time - I've been working on this post for a week now, so I figured it was time to publish and get the rough draft out...

Another half-baked idea, brought to you by the letter K and the number 14...
Saturday, May 28, 2005
  No Sun in Sight
Well, here it is - Memorial Day Weekend - and there is no sun in sight. How depressing. I was hoping for a fun weekend out in the park riding my bike and maybe getting in some photography. Now it is raining, and there is rain forecast for all weekend.

On a brighter note, I don't have to go in to clinic on Monday, because it is a holiday. I think this is the first holiday (besides Christmas) I've had off all year. I'm so excited. I'm probably going to sleep all day!!

So, now I'm on my Osteopathic Manipulative Medicine (OMM) rotation. It hasn't been nearly as bad as I thought it would be. The patients are mostly healthy, and only have a few musculoskeletal complaints. It's nice to see someone come in complaining of pain and leave feeling considerably better and to think, "I did that." It's a very empowering feeling.

In other news, I've been asked to work on an article for the EMRA web site about Osteopathic medical students and the choices we have to make in going into Emergency Medicine. Many of these are common to all Osteopathic medical students, but there are some differences. Right now, I'm in the data-collection phase and will hopefully open the paper soon. Of course, I also have to write a case report for the OMM rotation - I'd like to find some way to tie OMM to EM: Maybe, "The Use of Osteopathic Manipulative Treatment in Non-cardiac chest pain," or other such topic.

I've also been looking at internships/residencies recently (as always). I'm still looking to go up to the northeast - where I would like to end up eventually. I still have a favorite 1 or 2 programs I'd like to enter, but I've widened my search a bit. I now have a half-dozen or more other programs I could thrive in. Most of my criteria are met in each of these, and they have only one or two flaws (in my eyes), so I am willing to train there, if need be. So, now I have roughly 8 programs to apply to.
The internship search is stalled at 3 programs, however. Each of these are larger institutions with a few ACGME programs that also have AOA internships offered each year. So, the plan is to apply to one of these internships during the 2006 match and then apply to my EM programs during the 2007 match season.

Sure, that will extend my training to 4 years, but I think it will be worth it to insure that I can practice in any state in the United States in the end. I, like Matt M., am unwilling to completely sever my ties with the AOA at this time (although I think about just saying "F*** them" almost every day). I hope that in years to come, the AOA hierarchy comes more to the middle and is willing to discuss issues important to ALL members, not only those so ingrained in the osteopathic philosophy that they cannot see past their own nose. I'm hoping and praying for that day to come. Maybe we can all say a little prayer.
Wednesday, May 11, 2005
  Great News!!
I received word the other day that I was appointed to the Medical Student Council of the Emergency Medicine Residents Association (EMRA) as a regional coordinator for Texas, Arizona, Nevada, and New Mexico! I was so excited! I applied for this position a couple of months ago and have been waiting for news ever since.

Hooray for me!!

What does this mean? Well, basically I am now part of an organization dedicated to spreading the word about Emergency Medicine and coordinating the medical school interest groups in the above-mentioned states and providing them information about EM and EMRA. We also coordinate and organize the residency fair at the American College of Emergency Physicians Scientific Assembly in Washington, D.C. this September. Basically, we try to get as many residency programs to come and show their wares at the Scientific Assembly so the students can get a glimpse of what they are all about: what the program offers, the format of the program, patient population and volume, etc. We also encourage student research and increased education about EM topics in medical school curricula.

Check out the EMRA website for more information about what we do and what we are all about.

Ok, I'm done advertising for now. I just wanted to share the good news.
Tuesday, May 10, 2005
  Patient Files: Volume 2
Patient: G.C.
Age: 57
Race: Caucasian
Date of Visit: 5/10/2005

History of Present Illness:

Mrs. G.C. is a 57 year old caucasian female presenting to the Urgent Care Clinic with complaint of a "roly poly" underneath the skin of her right forearm. She noted this has been present for the past 1-2 years, is not tender unless it is traumatized, and has slowly been growing in size since she first noticed it. It has not caused her any problems, but she would like it evaluated because of fears of malignancy.

She also complains of right neck, shoulder and arm pain on and off for the past year after lifting heavy boxes at school, where she is a teacher. She has taken ibuprofen for pain relief, which has been effective, for the most part, and brings this up only because it has begun to bother her again in the past 2 days. She denies any weakness, paresthesias, change in temperature, or numbness of the affected extremity - only pain.


Mrs. G.C. has hypertension, which is currently treated with a beta blocker and a thiazide diuretic, and hyperlipidemia, which is treated with a "statin."

Family History:





As noted above, she takes a beta blocker and thiazide diuretic for hypertension, a "statin" for hyperlipidemia, and occasionally takes ibuprofen for pain relief.

Social History:

She is married with grown children. She lives in the surrounding area in a house with her husband. She is a teacher at a local junior high school. She denies tobacco/EtOH/drug use, but admits to smoking when she was younger.

Physical Exam:

Mrs. G.C. is a well developed and well nourished middle aged female. She is in no acute distress.

Her HEENT, CV/Pulmonary, and Abdominal exam are negative. Breast and GU exams are deferred.

Upon exam of her right upper extremity, a 3x2cm soft, mobile mass is appreciated on the dorsal radial surface of her wrist. It is nontender to palpation, is not hot to the touch, is not erythematous, and does not demonstrate fluctuance or a cystic character. There are no apparent overlying skin structure abnormalities and functional testing of her right wrist and elbow are normal. Muscle strength is 5/5 in the right upper extremity and there is no abnormality in the neurovascular exam.

Examination of her neck and right shoulder reveal decreased PROM and AROM of the cervical spine and right shoulder joint. There are multiple tenderpoints identified in the shoulder and cervical musculature. Again, strength and neurovascular examinations are WNL.

Differential Diagnosis:

"Roly Poly:" lipoma, ganglion cyst, epidermoid cyst, tenosynovitis, traumatic injury, arthritic changes, soft tissue sarcoma

Neck/Shoulder pain: arthritis, traumatic injury, cervical disc herniation with nerve impingement, somatic dysfunction NOS, tenosynovitis

Diagnosis and Treatment:

After consultation with the patient, a diagnosis of lipoma is considered most likely. The decision is made to observe this for now, since it is not causing a problem at this time. The patient has an appointment with her PCP in 1 month and is instructed to discuss this finding with her PCP at that time and have the PCP monitor for growth or change in character. We discussed the possible future need for biopsy or excision of this mass - the patient understood and agreed with the above plan.

Regarding the neck and shoulder pain, the patient was offered the following: stretching exercises, continued use of NSAIDS, physical therapy referral and NSAID therapy, trigger point injection and NSAIDS, or observation. The patient decided upon a trigger point injection, noting she had one previously and received relief afterwards. The patient was counselled regarding the risks and benefits of trigger point injection, to which she agreed and still desired treatment.

After the trigger point site was identified, it was cleansed with betadine and alcohol. The site was topically anesthetized with ethyl chloride and 1% lidocaine was infiltrated into the area to provide deeper anesthesia. Afterwards, a 25g 1.5 inch needle was introduced into the trigger area. The plunger was withdrawn and a few bubbles were noted in the syringe. The needle was withdrawn approximately 1 cm and 2cc of a marcaine/kenalog solution were injected into the trigger point and the surrounding area. The needle was withdrawn and the injection site was covered with a bandaid.

The patient was observed for 15 minutes as per clinic policy after an injection and the patient was released home with samples of an NSAID for pain. She was told to return if symptoms did not improve or worsened.

Approximately 30 minutes later, the patient returned to the clinic complaining of shortness of breath and chest pain. She stated this had been progressing over the past 20 minutes until she felt she could not breathe. Her SaO2 was 97% on room air, her respiratory rate was 28-30, pulse 110, and she was in mild respiratory distress. Lung examination revealed slightly diminshed breath sounds on the right. Cardiac exam was normal aside from tachycardia. A stat chest xray was ordered to rule out pneumothorax and the patient was placed on O2 at 2L/min via nasal cannula.

The xray showed a 10-15% pneumothorax in the right apex. The patient was sent to the Emergency Department for treatment.

In the ED, she was observed and a repeat CXR in 6 hours showed no increase in pneumothorax size. The patient was admitted overnight for observation and a repeat CXR in the morning. The next morning, she was released to home, feeling better.


This case illustrates that any procedure has attendant risks, for which we must always be watchful. A seemingly benign procedure performed a thousand times without problems by this particular physician produced a harmful (and potentially deadly) complication. Fortunately, she recovered well and had only a little morbidity.

Pneumothorax (PTX) is air in the potential space between the parietal and visceral pleura. This space is usually occupied only by a few milliliters of serous fluid to lubricate the layers as they move against each other during respiration. PTX has many causes: penetrating wounds, ruptured emphysematous bullae, fractured ribs, etc. Many times the cause is unknown, as PTX occurs in seemingly healthy young people (usually males) in a familial pattern, frequently causing a tension PTX. This is a condition in which air is extruded into the pleural space through a one-way valve and cannot escape. As a result, the intrapleural pressure increases and the lung tissue and mediastinal contents are forced into the contralateral hemithorax, reducing blood return to the right heart and thereby reducing overall cardiac output.

The signs and symptoms of PTX include dyspnea, hypoxia, tachypnea, anxiety, decreased breath sounds, decreased SaO2, and pleuritic chest pain. These symptoms may vary depending on the size of the PTX. Tension PTX may present with decreased breath sounds, tracheal shift away from the midline, and hypotension or shock. The patient may or may not be conscious.

PTX is diagnosed by chest xray. If the PTX is small, an expiratory film may be required to see the air in the pleural space. Diagnosis can also be made by chest CT, but this is much more expensive. Tension PTX is a clinical diagnosis, since the patient will most likely be dead before a chest xray can be performed.

Treatment of PTX depends on the type and size. Tension PTX is a medical emergency requiring immediate action. An 16 or 18ga angiocath is inserted into the pleural cavity in the second intercostal space in the midclavicular line to immediately relieve the pressure and convert the closed PTX into an open one. A tube thoracostomy is then inserted and set to water seal and wall suction. Non-tension PTX are treated much the same way if they are significant, with the exception of the angiocath insertion. If the PTX is small and non-progressing, the patient may be observed to insure resolution and discharged home.

In patients with hereditary bullous disease of the lungs, surgery to remove the bullous areas of lung must sometimes be performed (lobectomy or segmental resection) to prevent recurrent PTX.


Upon talking with Mrs. G.C. after her discharge, she said she was feeling much better - her dyspnea had resolved and she no longer had any chest pain. Best of all, she said her shoulder no longer hurt as well!
Tuesday, April 19, 2005
  Patient Files: Volume 1
Patient: R.B.
Age: 29
Sex: Male
Race: Caucasian
Date of Admission: 4/19/2005

History of Present Illness:
Mr. B. is a 29 year old caucasian male admitted from the Psych ER on detention warrant from home where he was found by police to be running around his mother's house yelling that "someone brown is chasing me with a gun."

The police searched Mr. B and the surrounding premises but were unable to find any weapons. Upon speaking with his mother, it was found that Mr. B had become progressively paranoid after running out of his Risperdal 3 days ago. They also discovered he has carried a diagnosis of paranoid schizophrenia for the past 3 months after being diagnosed at a hospital in his hometown. He has been taking Risperdal 2 mg po BID, Paxil 20 po QD, and an unknown dose of Atarax since that time - until 3 days ago when he ran out of Risperdal.

Because of his increasing paranoia (and psych history), the police officer took Mr. B into custody and brought him to the Psych ER for evaluation.

In the Psych ER, Mr. B was aggressive and not cooperative. He said he knows someone is trying to kill him and that he cannot stay there. He also made references to being psychic and made the comment, "See all these buildings, they will not be here soon."

Mr. B denies any suicidal or homicidal ideation. He repeatedly stated, "I get like this when I'm off my medication," and frequently requested that he be re-started on his medication.

Upon continuation of the diagnosis of Paranoid Schizophrenia, Mr. B was admitted to the inpatient psychiatric facility for further evaluation and treatment.

Mr. B denies any past medical history

Past Psych Hx:
None, other than the above noted hospitalization and diagnosis of paranoid schizophrenia. He denies ever taking any other psych meds than the ones he is currenly taking: Risperdal, Paxil, and Atarax.

Social Hx:
Married x 5 years. One child (2 year old son), currently living in his hometown with his wife. Mr. B is currently living with his mother as he works in concrete construction to pay for a house he is buying back in his hometown. Denies any arrests or legal trouble.

Past Substance Abuse Hx:
Denies tobacco, alcohol, and illicit drug use

Family Hx:
Significant for cancer (breast, prostate) and hypertension.

Labs: - (obtained after admission) -
CBC: Within Normal Limits (WNL)
DAU: + methamphetamines; - cocaine, cannabis, benzos, opioids

Upon further repeated questioning and confrontation, it was discovered that Mr. B had indeed used methamphetamines 2 days before admission, although he denied regular recent use. He admitted to frequent use 2-3 years ago, along with cannabis use. He claims to have only smoked amphetamines, never used them intravenously.
He still claims to be out of his risperdal for the past 3 days, and denies that methamphetamine use could be the cause of his symptoms.

After further review, Mr. B's most likely diagnosis is Substance-induced Psychotic disorder. However, at this time, paranoid schizophrenia cannot be ruled out. This brings up an important point - whenever making any psychiatric diagnosis, two things must always be ruled out:

1. The psychiatric disorder cannot be caused by another medical condition
2. The psychiatric disorder cannot be the result of drug use

This is very important to remember, because many drugs and medical conditions can look very much like psychiatric disorders. The classic examples are amphetamine use and bipolar disorder/manic episode, hypothyroidism and depression, and cocaine abuse and psychosis. Distinguishing these can often be difficult in an acute setting, which is why NOS diagnoses are so common in the acute period. This non-comittal diagnosis gives the physician time to sort out the details needed to make a more informed final diagnosis.

This also points out the danger in simply 'carrying forward' a diagnosis another physician has given a patient - especially a new diagnosis. While Mr. B's psychosis may be due to paranoid schizophrenia, in the setting of recent drug use, we cannot make this diagnosis for sure until all effects of the drug have worn off and we see his baseline mental status.

The treatment of psychosis depends on its cause.

If drug induced, one must simply wait until the drug effects wear off, with symptomatic medications used only for agitation and violence. In this case, a typical antipsychotic (haloperidol) along with a benzodiazepine (lorazepam) and an antihistaminic/anticholinergic (diphenhydramine) cocktail may be given intramuscularly to sedate and calm a patient.

When using typical antipsychotics, one must remember to watch for Neuroleptic Malignant Syndrome (NMS), which is a dangerous, sometimes life threatening idiosyncratic reaction to antipsychotic medications. In NMS, the patient's temperature rises, he develops muscular rigidity (lead-pipe or cog-wheel), increased agitation, and elevations in blood pressure and pulse rates. He usually develops rhabdomyolysis (mild to severe) and may develop myoglobinuria and acute renal failure. It is important to determine whether an increase in agitation is just that or the early signs of NMS, since if it is wrongly determined to be increased agitation and further doses of antipsychotics are given, NMS may be worsened. NMS is more common in young men and with recent onset of use of typical antipsychotics.

If psychosis is caused by another medical condition, such as porphyria, temporal lobe epilepsy, or other medical condition, treatment of the medical problem will usually result in resolution of the psychosis.

If psychosis is determined to be caused by a mood disorder, appropriate treatment of the mood disorder (with interval treatment with antipsychotic medications) will result in resolution of the psychosis.

If it is caused by schizophrenia (or other psychotic disorder), treatment with antipsychotic medications is the best treatment. Antipsychotic medications come in two varieties: typical and atypical.
Typical antipsychotics (aka neuroleptics) are older, cheaper and have more side effects. They are dopamine receptor antagonists, and thereby have all the problems associated with dopamine blockade: parkinsonism, other movement disorders, hyperprolactinemia, etc. However, they work very well for what are called the "positive" psychotic symptoms. These include hallucinations and delusions - things that are there and are not supposed to be (positive means added). These drugs all cause sedation and have varying degrees of anticholinergic and antihistaminic effects as well.
Atypical antipsychotics are newer, more expensive, but have the added bonus of being cleaner (i.e. fewer side effects) and they are more effective against the "negative" psychotic symptoms. These include flat affect, thought blocking, alogia, apraxia, psychomotor retardation, lack of self care, poverty of speech/thought - things that should be there and are not (negative means taken away). These drugs are thought to work by interacting with sertotonergic receptors rather than dopaminergic receptors (although they do that as well - although to a lesser degree than the typicals). This is partly why they have fewer of the icky side-effects of the typicals. It is believed that by altering the serotonin levels in the limbic system and basal ganglia, norepinephrine levels will increase - causing an improvement in negative symptoms. The little bit of dopamine antagonism these drugs have also help take care of the positive symptoms of psychosis.

The boo-bad thing about the atypical drugs is that they have freaky side-effects. For example, clozapine causes agranulocytosis in about 1% of the people that take it. Not too good. As a result, the patient has to have blood tests weekly for the first 6 months they take it, then every 2 weeks thereafter. Kind of a pain in the butt. Another of the atypicals, olanzapine, causes problems with weight gain, insulin resistance, and increased LDL cholesterol - so if you have a patient with metabolic syndrome or diabetes (or even a strong family history) you'd better not give them this drug unless you want to be sitting in a court-room pretty soon.
But even with these side-effects, these drugs have turned many people's lives around for the better.

After 1 day of inpatient treatment, Mr. B's psychosis cleared. He was restarted on his Risperdal and his Paxil and Atarax were continued per his request. Given his rapid return to baseline, it was felt that his psychosis was indeed most likely caused by amphetamine use. However, because we have no way of determining his true psychiatric history at this time, his psychotropic medications have been continued. We are currently awaiting records from his private psychiatrist before any further determinations are made.


Ok. Here ends Volume 1 of The Patient Files. As you've seen above, the cases will most likely reflect what I am seeing on my current rotation, since I can't remember many details of past patients. Please feel free to ask questions about the cases or post your own cases.

I've had fun with this - and it helps me refresh my memory for the shelf later.. how better to learn than to teach, right?

Wednesday, April 13, 2005
  Psychosis and me
It was the best of times, it was the worst of times.

It was a month on the psychiatry service at the busy county hospital.

It's been a whole boat-load of fun so far. Let me tell you about it.

During our psychiatry rotation, we do 2 weeks on an inpatient unit and 2 weeks in the psych ER. I started with the psychiatric ER because I thought it sounded more fun than the inpatient side. Also, there was a rumor that the inpatient unit usually gets out early every day, so I thought it would be cool to have the time to study for the shelf in the last 2 weeks. So far, it has worked out pretty well for me.

The first 2 weeks, as I noted above, was spent in the psychiatric ER. This time is spent triaging patients that either present to the ER or are brought in by the police. Those that come on their own are called "voluntary" (obviously), while those that come in by the police are in on warrant. A warrant can be of two types: magistrate's warrant or detention warrant. The difference is that a Magistrate's warrant is initiated by a family member, roomate, etc when they are concerned for their family member or friend and a detention warrant is served by a peace officer when he or she feels that a person is a danger to himself or to other people.

So a person comes in voluntarily or is brought in by the police and is evaluated by a physician (or student). It is then determined what the best course of treatment would be for said patient, whether it be admission, discharge, referral to counselling, or drug rehab. The unfortunate thing is, many patients are shelter-seeking or drug-seeking and are very medicine-savvy, so the challenge is to determine when a patient is truly a danger to himself or others or whether they are in-fact malingering. Fortunately, many of the return patients are known to the department as recidivists, so are appropriately turned away when they come to the psych ER looking for 3 hots and a cot.

It is very interesting talking to patients when they have not previously been worked up and trying to come up with a good differential and provisional diagnosis. The problem with psychiatry is that many times one cannot make a definitive diagnosis because it is very difficult to gather all the required information from the patient and all involved relevant family members. As a result, many patients are dispositioned with a provisional diagnosis, such as Depression not otherwise specified (NOS), psychosis NOS, or mood disorder NOS. The two most common diagnoses in the actual psych ER (not the clinic or walk-in part of the psych ER) in my experience are psychosis NOS or substance-induced psychotic disorder.

Overall, this was a very exciting two weeks for me - I had a lot of autonomy since the student is truly the major caretaker for all the patients, and the attendings and residents have more of the role of consultant and advisors. By the end of the 2 weeks, I felt fairly comfortable in the psych ER, although there were always times I worried for my life. There are many crazy people here.

The second 2 weeks of the rotation are spent in the inpatient unit here at the county hospital. It serves people admitted from the psych ER - mostly those that are indigent and have no insurance. If they have insurance, most of them go to other facilities. This is very unfortunate, because I feel that the experience I am having is somewhat skewed because of the patient population I am serving. These people are medically underserved and therefore often have chronic medical problems that are uncontrolled on top of their psychiatric problems (or possibly causing their psychiatric problem).

The typical day on the inpatient unit is arriving between 7 and 730am, seeing the new patients that were admitted overnight and also re-evaluating the patients we already were seeing the days before. Then, we have all the patients come into the group with us (staff physician, residents, medical students and a social worker) and discuss their progress from the day before. Sometimes, there is some therapy that occurs at this time, usually minimal, and then we move on to the next patient. The cycle repeats itself until all the patients are seen in a day. If the patient is aggravated or dangerous, we see them on the unit where there are other people around to help if a situation arises.

This part of the rotation has been pretty boring to me thus far. I am not much for sitting around and talking to people in a group (mostly listening to people, since the attending does most of the talking). I haven't really cared for this part so much.

A couple things I have noticed since starting this rotation: 1) My problems are VERY VERY insignificant compared to these people's. This makes me feel much better about myself. 2) I have noticed in both myself and my classmates that are on the rotation with me, more psychiatric problems. I don't know if this is because I am more attuned to these clues or if being around the crazies induces craziness in others. Something like a shared psychosis (folie a deux - a truly excellent X-Files episode if you haven't seen it). I've always wondered if insanity could be communicable.

I know it isn't - but it is still a interesting thing to think about.

For instance, I have noticed more hypo-manic or manic symptoms in myself since starting this rotation. As I said before, I'm not sure that this isn't because I'm more savvy and recognize the symptoms more readily or whether there is, in fact, an increase in the symptoms. I think I'm usually a pretty "up" guy, but I don't think I'm usually as "up" as I have been the past couple of weeks. Weird association...

What do you think? Anyone else have a similar experience?
Thursday, March 31, 2005
  The End for Terry Shiavo
Terry Schiavo Dies - From USA

Terry Schiavo - a name I have loathed hearing ever since I heard it the first time last year. A case embroiled in bitterness and folly. A case that completely demonstrates how stupid our country really is.

The right to die, indeed. More like the right to suffer interminably (if your family has anything to say about it)

What pisses me off so much about this case (among many other things) is that this should never have happened. If Michael Schiavo said she would not have wanted to live in that state, the tube should have been pulled 15 years ago. The line of decision making is from immediate family (husband, adult children) to extended family (parents, siblings) if there is are no formal instructions. The U.S. public should never have even heard of this case, much less have to see it plastered on the front page of every news magazine for the past year.

And the Florida Legislature and Jebby Bush? I am calling for their resignation right now. Actually, I am calling not only for Jeb Bush and the Florida Legislature's resignation, I am calling for George W. Bush and the U.S. legislature's resignations as well. It was not their place to intervene in this case, nor any other personal case. This sets a VERY dangerous precedent for the future in this country.

I do not look forward to what is soon going to happen in this country; all in the name of a "creating a culture of life." I certainly hope the American people will be as quick to stand up for their right to die peacefully and with dignity as they have been to "live" despite all evidence to the contrary.

Advanced Directives - From
10 Legal Myths about Advanced Directives - From the American Bar Association (ABA) web site
Links to Advanced Directive Forms for the U.S. - From

The one good thing that came from this case: That the entire nation is finally learning about advanced directives and durable powers of attorney. For too long have we been taken unawares by our own injuries and near-deaths and found ourselves in similar circumstances as Mrs. Schiavo - getting treatment we would not want. Maybe now so much spotlight has been placed on the issue, more people will complete an advanced directive or durable power of attorney.
Monday, March 14, 2005
Well, I'm on call for the 2nd of 4 times this week and I must say that it really blows. Right now I'm on what amounts to a q2-3 call. I was on call saturday, now monday, then thursday, then sunday again. Yuck. Plus, I have a research project to complete this week and the school's email server is down so I can't retrieve what I've done so far and continue working on it.

I hate my life sometimes. The good news is I'll be done with this rotation soon. Sorry I haven't really said much about it - I just don't figure anyone reads my posts anyway and thus far (4+ weeks into the rotation) there isn't really much to talk about. This town is small and it sucks, the hospital sucks, the rotation director made it very clear to us that he doesn't like students from our school, and I'm feeling just a bit bitter about being sent out here to B.F.E. for my OB-Gyn rotation right now. The only cool thing is that I have pretty cool room-mates and most of the residents are actually cool to work with - not that there is much work to be done.

To this point in my OB-Gyn career, I have seen no deliveries and only one cesarean section. Most of my time on call and in this rotation has been sitting around waiting for something to happen, but it never does. Of course, there were the weeks of "surgery" and "clinic," both of which were about this exciting.

I feel sorry for anyone that has to follow us out here - it is really the pits.

Onto happier thoughts now - only one and one half weeks left on this rotation, then back to home-sweet-home! I'm so ready. One cool thing that I did while I was here is I went skiing. There is a ski resort only 4-5 hours away, so on my weekend off I went up there and tried to kill myself again. Next time, I'm going to try my hand at snowboarding - I'll probably really break my neck then!!

Nothing else really happening with me right now. Just watching and waiting - and trying to decide where and when I want to do all of my 4th year electives... It's time to get this stuff finalized and scheduled already. Of course, the school is being almost no help, which is about true to form for them. Tomorrow (after I have a nap after call) I'm going to make some phone calls and get some stuff settled already. I'm tired of the endless waiting for answers that never come. I'll just take things into my own hands.

So, here is a tentative list of 4th year electives - if I can fit them all in when and where I want them:

* Anesthesiology
* Emergency Medicine x 2 months
* ICU/MICU/CCU (whichever)
* Radiology
* International elective/Medical Spanish elective (if I can get it approved by the school - which I hope)

Possibles include Cardiology (preferably with a large EKG/arrhythmia/acute MI component), a pedi EM or PICU month, and there is something else I can't think of right now. The biggest problem is that almost all of these will be away rotations, which means big $$$. I hope there are loans we can take out for all this travel and stuff.

Then there is step 2 of the boards. I haven't decided whether to take USMLE step 2 as well as COMLEX 2 or not. I've considered it, just because I think it would make me more competitive for my residency spots if I had USMLE steps 1 and 2 available when I apply, but that's another test to take, etc, etc, etc.

Of course, the whole residency thing is still pending as well. I don't really have to worry about it, because I think I'm going to take a rotating internship after school and apply for final residency during my internship. I don't know if I agree with the philosophy of the internship year, but the area in which I want to practice is one of the "famous 5" and I don't want to screw myself out of licensure by not taking the internship year and then not be able to get the year approved. So I'll take the hit, be a slave to the AOA for a year, then I'm off to the races.
Saturday, February 26, 2005
  The Super Aids
Unless you've been living under a rock for the past month, you know that "Super AIDS" has struck New York and, according to some reports, San Diego.

In case you have been under a rock, read the above sentence.

What is "Super AIDS?" It is a strain of HIV that is Multi-Drug Resistant (MDR) and quickly progresses to AIDS. The first case was reported in New York earlier this month when a man in his 40s was discovered to have an especially virulent strain of HIV. The real kicker is that he tested negative for HIV several times over the past 4 years - the last of which was less than 20 months before his diagnosis of AIDS.

What does this mean? Either the tests were wrong, or this man has a strain of HIV that progresses from nothing to AIDS in less than 2 years. This is really scary, people. Really scary.

The last I've heard or read, researchers don't know whether this strain of HIV can be transmitted (although two people with the same strain would point in that direction). It seems that, in general, as a strain becomes more virulent, it tends to become less transmissible. They also don't know whether his repeated use of methamphetamines may have played a role in his contraction of HIV or his rapid progression to AIDS, nor whether the strain is especially virulent or perhaps it was the interaction of the man's immune system and this particular HIV strain. What they do know is this particular strain of HIV is resistant to three of the four classes of drugs used to treat HIV - something that does not usually happen unless prior treatment has failed.. I guess we'll just have to wait and see what the researchers find out about this particular strain of SUPER HIV.

Bottom line, people, is watch what you are doing and with whom you are doing it. If there is any question as to whether you (or the person you are with) are clean, get checked immediately.

Oh, and please don't get trashed and just screw anything that moves. I know it's hard, but self control is one of the hallmarks of society. If you can't control yourself, go live on an island by yourself. The rest of civilization doesn't want you around.

This doesn't just go for sex, either.
Wednesday, January 19, 2005
  Things we do to our children
You've all met or heard of someone that's done it - maybe it's even you that everyone else knows. Those people that feel the need to come up with a novel name for their child.

Please, please, whatever you do, don't be clever or cute or novel. Stick with the tried and true and do not subject your poor innocent child to years of torment and ridicule because of their name.

Where did this diatribe come from? Of course, I am on pediatrics - where else? (Not that I would ever be known to rant about anything, right??). I'm currently on my inpatient pediatrics rotation at the local children's hospital. The doctors with which I am working have made a list of the strangest names they have come across. Of course, almost everyday we've had a discussion about this list of names and the possible reasons parents might have for dooming their children for decades to come.

And the list includes:

1. Sunshine
2. Rusty Lance (I can't even comment on this one.. hopefully the kid will enter a monastery before the age of 3)
3. Nucleus (always has to be the center of attention)
4. Tyberius
5. Tomango (mom's name was tomato, dad's was mango - just kidding)
6. Bam Bam (Flintstone kids, 10 million strong and growing!!)
7. Serenity Faith
8. Divinity Trinity
9. Celestia Unique
10. Abid Nagi
11. Seven (hopefully not named in sequential order)
12. Shanequeneshea (nothing to say, but WTF?)
13. Yovanka
14. Treylon Omega
15. Ebony Queenette
16. Patriarche
17. Temia
18. Genesis
19. Dkayla
20. Neveah (heaven spelled backwards)
21. Melvinisha
22. Dasani (always reminded to drink their 8 ounces of water a day)
23. Keyarra
24. Bronshay
25. Rastus
26. Quanshave
27. J'tavion
28. Female (fem-mall-ee
29. Pajama (paw-je-ma)
30. Shithead (pronounced shitheed)
31. Abcd (pronounced ab-see-dee)

See what I mean? What are these people thinking? Naming your kid after a bottle of water? Puh-leeze.

May I please, please, please, please, please admonish you to stick with the tried and true names and don't be cute or clever. Your child will thank you forever.

Also, if you know of a good reason why a parent would do this to a child, please let me know. I am almost dying to learn the reason for this travesty.

BTW, family names are not included here, although some family names are quite unfortunate. Family pressures are often much stronger than you would believe.

more to come
Friday, December 17, 2004
I've never really understood why some fields of medicine still spell their names in the old english fashion (well, actually - originally latin). These seem to be hoitey-toitey people within the fields that do this - paediatrics, orthopaedics, etc... like orthopedics isn't hard enough to spell without throwing a dipthong in the middle of it. And then, there's the question of how to pronounce it. Orthopedics, easy enough (oar-tho-peed-icks), right? However, with the dipthong in place, the 'ae' actually make an "eye" sound.. so now orthopaedics = "oar-tho-peyed-icks" (non-syllabic splitting of the word done purposefully in order to not reference the male member). How confusing. Paediatrics = "peye-dee-at-ricks"

To keep it easy:
Orthopaedics = Orthopedics = Orthopod
Paediatrics = Pediatrics = snot-nosed-brat doc (just kidding)

Regardless of how you spell it, say it, or do it, ortho is a pretty cool rotation. Aside from the long hours (which were pretty bad after my 2 weeks on vascular = cush) - 7 or 8am until at least 5pm at various places throughout the city and surrounding towns - I really enjoyed it alot. The docs I worked with were really cool and had insane senses of humor (or is it humour?) and joked constantly. I was pretty much always laughing at something. They were also pretty nice to me, which is very different from what I'd heard of the ortho rotation. Maybe they did the same thing to me as everyone else and I took it differently? Who knows. All I know is I had fun, I learned some stuff, and ortho surgery doesn't suck nearly as badly as general surgery. Actually (and I never thought I'd say this), some of the procedures are quite fun.

Now don't worry, it'd take a lot more than carpentry on humans (POWER TOOLS!!), 400-500+K/year, and the reputation as someone you don't want to mess with to make me change my mind about Emergency Medicine - so settle down. :) Frankly, I don't think I could be gruff like that - although I have been known to be quite nasty from time to time.

Anyway - FINALLY, surgery is over. Now for christmas break and a long needed vacation. I'm going to Maine to go skiing for the first time in my whole and entire lifetime (and hopefully to not break my leg and need the services of those same orthopods with whom I just rotated). Needless to say I am both excited and terrified - considering all I know about the surgeries involved to repair the various and sundry injuries to the osseous structures of the lower extremity. My father broke his leg skiing - these things run in families, you know.

Glad to be finished with "the hard block" of Internal Medicine, Family Medicine, and Surgery. Next is on to the slighly less hard block of Pediatrics and Ob/Gyn (each 6 weeks in length). I'm not really looking forward to these at all... snot-nosed kids and (forgive my french) cootchie is not my idea of a good time - especially when they are all together (childbirth). More power to you if you are trying to become pregnant, but don't be coming here to give birth to your baby.. especially if I'm on call for Ob... Blaech!

Ok.. must away to finish my christmas shopping - I have only like 2 more people to buy for and I'm finished!! Of course, christmas is next saturday, right? Ok.. maybe I'm not doing as well as I thought..

later all...
Friday, December 03, 2004
  Vascular Surgery: Done and finished
I finished vascular surgery today. Overall, it was surgery - so it sucked. However, my preceptor was really cool. Very intelligent, very dry and crass. He was very cool. He and one of the other surgeons in the clinic were constantly back and forth with each other, cursing and joking with each other. The only thing I regret is that I didn't get to see much surgery. The only things that came in these past 2 weeks were vein strippings and port removals. These are not too interesting as far as surgery goes. My preceptor kept hoping for a good thoracic case, and, to tell the truth, so was I. I really liked the thoracotomy I saw in the ED last month and would like to have more experience with the patient with an open chest.

Anyway, today was my last day - and I found out yesterday there was to be an oral exam for this portion of my surgery rotation. Immediately, my stress level went through the roof. Actually, yesterday (at noon) when he told me about the exam, it was originally scheduled for yesterday afternoon. However, when I showed up, I waited for 45 minutes for him to arrive. Finally, he called and said he was stuck in a meeting, let's do it tomorrow.

So, I show up this morning ready for action (I think). I had no idea what this would be about - so I had to prepare for everything. The last day I read and re-read the vascular, thoracic, and pulmonary chapters so I would be prepared for everything and anything. I walk into his office, say "hi," and after the usual morning pleasantries we begin.

In actuality, it wasn't bad. It was a number of scenarios with patients that have vascular and pulmonary problems. I didn't know a lot of the questions he asked, but it wasn't very stressful and he never said "God, you're a f-ing idiot!" Not too bad at all.

Anyway, so my foray into vascular surgery is over. Next up is a 2 week Orthopedic surgery experience. And of course, today my vascular preceptor says the cool surgeries are now starting to come in... My crappy luck is quite intact.

more to come....
Sunday, November 28, 2004
  The Eternal Sunshine of Vascular Surgery
One week through vascular surgery (although, not really a true week, since Thanksgiving fell right in the middle of it) and I must say all is going well. I like my preceptor - he is a huge smart-ass, just like me. Also, I have not had to be in surgery yet, both because of the holiday and because of the slow holiday season. Again, playing into my dislike of the O.R. I've done a lot of reading over the past week, attended several lectures, and had a bit of free time.

The only downside of the past week has been the impending doom of the holiday season looming over my head. I have yet to seriously begin shopping for my loved ones, and christmas is only 4 weeks away. I like spending the holidays with my family and loved ones, I just hate trying to come up with a gift that each will like and fits them well - especially now that I almost never see them. That makes it really hard to know what they would like or what they need. I don't like getting gift certificates, since I see that as a 'cop-out,' but sometimes I don't see any other choice: I could get them something they don't like, they can take it back and then spend the money on something else, but what would be the point of that? Why not just give them the money and save them the trouble of standing in line to return it? Oh, yeah - because it's a cop-out.

Catch-22, here I come.

I hate it when I say something and it reminds me of a medical condition (CATCH 22 is a mnemonic for the symptoms of DiGeorge's syndrome. It stands for Cardiac abnormalities, Abnormal facies, Thymic dysplasia, Cleft lip, Hypocalcemia - all due to a deletion on chromosome 22). I'll be driving down the road and I'll see the letters on a license plate and think, "hmmm.. DVT: Deep vein thrombosis," or something similar. It drives me nuts. I've done it for years, and it's always made me crazy.

And now, on to something completely different:

I watched The "Eternal Sunshine of the Spotless Mind" the other day. Wow. I really didn't know if I'd like it (I had no idea what it was about..), but I rented it the other day. I must say, it had an amazing message. However, even if you don't get to the deeper meaning, the idea of the film is interesting: How many people would like to erase something that has happened in their past, but they are forced to live with it? This movie purports there is a way to absolve yourself of that suffering. The deeper meaning is what makes this movie really special, however. For those of you that have seen the movie, you'll know what I mean. If you haven't seen it, do so now - I highly recommend it.

Maybe sometime in the future we can discuss the movie. I just don't want to spoil the film for anyone.
Friday, November 19, 2004
  Finished with General Surgery
Finally!! The torture of q4 is over! And I managed to get through surgery without excessive OR time. I chose my cases carefully to prevent repetition and boredom.

This rotation has only further increased my interest in Emergency Medicine. How? you may ask. Well, I'll explain: When on call, you are the trauma surgery team. That means every major trauma that comes into the ED, you get called on and participate in the emergency resuscitation of said patient. It was really cool!! I've already written about the ED thoracotomy I witnessed, and that was by far the most dramatic event of the month, but there were many other patients we saw. Fortunately (or unfortunately, depending on how you look at it), someone in our group was a complete sh!t-magnet, so our call nights were always very busy with trauma and also other consults. The only bad thing about the whole situation is I am a student, and therefore get last dibs at every procedure. As a result, mostly all I did in trauma situations was a rectal exam (oooh fun!! But important all the same) and maybe insert the foley catheter. I did get to put in a central line, however, which was cool - especially since the intern had already missed on a previous attempt.

As a result of this surgery rotation, I have more experience in the ED resuscitation of trauma patients, and I love it as much as I always did.

So, today was my last day on general surgery. Since it's such a big rotation, my GF and I decided to celebrate by going to the Cirque du Soleil this evening. It was a really good show - I'd highly recommend it if you've never been. I'd also highly recommend it if you have been to see Cirque before. This show, "Varekai" is very well done. The best thing about Cirque du Soleil is that everything is done live on the spot - no nets, no pre-recorded music, no-holds-barred. The band is on the right, the singer is always in view (even though you can't understand what they say, since it's all either in French or a made-up language). The acrobatics are amazing, rope-work is stunning, and then there's always the super-psycho-flexible chica that can bend herself over backwards and put her head next to her butt... I always have problems with that - I wonder how can the human body be that flexible? The thoracic spine is not supposed to bend in that direction... It's really quite distressing if you think about it. Almost like when you see the video of an ACL going out and the knee just bends in an un-natural direction... eewww!

Ok. I'm finished babbling now. The next 4 weeks are specialty surgery: 2 weeks of thoracic/vascular surgery and 2 weeks of orthopedic surgery. Then CHRISTMAS BREAK!! and a much needed rest. I think we get 2 weeks!! I won't know what to do with myself. Any suggestions besides a nice 4 day ski vacation in Maine?
Wednesday, November 17, 2004
  A few thoughts...
Just a short entry...

I watched ER from last week, and was reminded of myself. No, I'm not the patient, but instead the physician.

I remember when I first entered nursing school - I was wide-eyed, open to everything. I always wondered about my patients: who are they, where are they from, what have they gone through in their life to get to here?
However, as time went by, and especially once I started working in the ED, I noticed myself caring less and less for my patients' story and succumbing more to the typical stereotypical point of view that so commonly grips medical personnel.

That is something that is so sad - that we, as medical professionals, become so desensitized to human suffering that Mr. Martinez (name made up) becomes "the lap chole in 507," or Mrs. Jones becomes the "uterine fibroids in 310."

I don't know exactly why it happens, but I have a theory. It goes a little something like this:
As human beings, we are emotional creatures. Our interactions (especially those of the depth required by a physician-patient relationship) require an emotional expenditure. With the number of patients we see in any day/week/month/year, the emotional drain would be enormous, so we (as medical professionals) try to limit our emotional expenditure by keeping a "professional distance."

Not to say this is good, but I think it is something of a psychological protection mechanism - to protect us from over-exerting ourselves.

Ok, I don't think I'm making any sense here... I'm quitting until I'm more rested. Thank goodness this surgery rotation from hell ends friday.
Sunday, October 31, 2004
I guess I'm the first to go through a surgery rotation. And you were wondering where I was the past 2 weeks, right? Let me explain -

First, I had the family medicine departmental exam and the NBME Family Medicine shelf a week past. I'd heard the Family Medicine shelf is the hardest of the shelves, so I took some time to study because I wanted to do well. That took a few days of hard-core studying, then 2 days of exams. The really sorry thing about it is after the departmental exam, we had to go back to the clinic. It isn't a bad idea, just not the best setup for studying for the shelf. I was worried, but I think I did fairly well on the shelf. I'll see in 4-6 weeks, I guess.

The weekend was a glorious time off. I didn't do a damn thing, except rest and relaxation. It was beautiful. I wish every day could be like those 2 days.

Surgery began last monday, 10/25/04. It began with an orientation (like every rotation). I thought it was particularly humorous when the head of the department of surgery told us we were to work no longer than 80 hours per week - including study and academic time. We are to divide our 80 hr/wk into thirds and divide it between hospital, academic (meaning lectures, etc), and reading.

Obviously, he has never been over to the hospital where I am assigned. It is a VERY busy county hospital where noone EVER gets out on time. Let me break down the past week for you - keep in mind, call is every 4 days...

Monday: 0700 (orientation) - 1400 = 7 hours
Tuesday (Call): 0600 - 2400 = 18 hours (call not finished)
Wednesday (Post-call): 0000 - 1600 = 16 hours
Thursday (clinic): 0530 - 1800 = 12.5 hours
Friday (Precall): 0600 - 2000 = 14 hours
Saturday (Call): 0630 - 2400 = 17.5 hours (call not finished)
Sunday (Post-call): 0000 - 1300 = 13 hours

Grand total for week 1: 98 hours

And remember, that's supposed to be 1/3 of my total time spent per week. I still have to read and go to academics for a total of 294 hours per week. The only problem with that is there are only 189 hours per week actually available.

I think it is important to spend time in the hospital in order to learn, but 1/2 the total time in a week is a little insane. The only good think about it is that we have had some really cool traumas this week. Sounds pretty morbid, huh? The thing about medicine, especially Emergency Medicine or Trauma, is that you become cynical and begin to view the morbid as exciting.

For instance, my first night on call (Tuesday) we had a patient with a GSW (gunshot wound) to the left anterior chest. He was shot by a police officer after he'd first tried to break into an apartment, flee the police, then shot at the cops. He was down for 15 minutes in the field without a pulse and an idioventricular rhythm on the monitor (per EMS). When he arrived in the ED, he was in about the same condition - no pulse, no pressure, no spontaneous respirations. He was intubated and manually ventilated. CPR was in progress and there were 2 large bore IVs draining wide open for volume support. His GSW was just below his left nipple; there was no immediately obvious exit wound. Given the location of the entry, we were concerned for cardiac and pulmonary damage. As a result, the chief resident performed an emergency thoracotomy. It was F-ING AWESOME!! I was performing CPR on the patient's right as he was opening up the left. He spread the ribs and about 2 liters of blood and fluid poured out all over the place. I could see the heart and lungs plain as day.
They delivered the heart from the pericardium and examined it. They found a large laceration in the posterior portion of the left ventricle - no wonder he didn't have a pulse or blood pressure, right?
They repaired the defect and everything was re-started. We were giving intracardiac epinephrine, direct cardiac massage, open defibrillation - the whole works. It rocked... in a sick and twisted sort of way.
The patient died - as most people in that situation do, but it still got all our blood pumping.

Ok.. I'll write more later. I've been up since 0530 yesterday - I'm really freaking tired.

And by the way, never ever EVER EVER EVER be on call when the time change goes back.. that extra hour really sucks.
Wednesday, October 13, 2004
  Medical Records Implant: Good or Evil?
Do I think the idea is good? Yes. Do I think it will ever actually happen? No. The ACLU would have a freaking field day with this one, as would every human rights group saying we would be tracked, we would be reduced to nothing more than numbers, etc, etc, etc.

While I appreciate their concerns, they have obviously never seen a John Doe in the Emergency Department at 0200, not known anything about them or their past history and had to make decisions about their care. Maybe then these groups wouldn't throw such a huge freaking fit!

Until then, enjoy the read!

FDA: Chip Implant Can Be Used to Get Health Records

WASHINGTON (Reuters) Oct 13 - A computer chip that is implanted under the skin won U.S. approval on Wednesday for use in helping doctors quickly access a patient's medical history.

The VeriChip, sold by Applied Digital Solutions Inc., is placed in the upper arm in a painless procedure that takes minutes, the company said.

About the size of a grain of rice, the chip contains a patient's identification number that corresponds to health information in a computer database. A handheld scanner can retrieve the patient's number from the chip, which emits radio waves when activated.

Proponents hope doctors will use the technology to find vital information about someone who is unconscious or having trouble communicating. The database could include details such as medication use, allergies and major health problems.

The chip implants have been used for years for various purposes such as identifying lost pets. But Applied Digital was not allowed to market the chips for medical use in the United States until the company received clearance from the Food and Drug Administration on Wednesday.

The FDA ruled in 2002 that it would not regulate financial, security or other uses of the chips.

Privacy advocates have voiced worry about the speedy transfer of sensitive medical information via computer. Applied Digital said the data would be kept secure.
Saturday, October 09, 2004
  Friday Night Lights!?!?!?
Well, I just returned from the movie theatre with my girlfriend. We went to see Friday Night Lights. Awesome movie. It really took me back to the good old days of High School football...

If you remember from my "bio," I'm originally from a small town in West Texas. Yes, both words should be capitalized because West Texas isn't really part of Texas - hell, it's just barely a part of the United States. If you're from West Texas, you know what I mean. Everything is different out there. There are no towns of 1/2 million; 100k is about as big as you get until you reach El Paso (which, disputably, is part of Mexico). From the day young boys enter kindergarten they are indoctrinated into the ways of West Texas Football. There is no sportsmanship, there is no U.I.L. rules, there is only winning. At any price.

I remember 2-a-days. What I remember most was dreading it for the 2 weeks prior to August, hating it while enduring it and being so very relieved when it was over. I really don't know how we survived those all-day practices in the 100+ degree West Texas heat, but we did. I compare it to the brainwashing a group of recruits endures during basic training - isolated from humanity, your family, humiliated, broken down, and finally rebuilt as a single fighting machine - your troop, your team. That is the only way I can describe the punishment, the pain, and the suffering we went through. By the time 2-a-days was over, we were ready to eat the other teams alive if we had to.

I think of those times with fondness. It really sucked while I was living it, but, in retrospect, they really were some of the best times in my life. There's just something about laying a good hit on a running back or quarterback that you never forget. It's a craving - once you've had it, you want more. And you can't rest until you get it again.

Damn, I miss football.

We had a different kind of "Friday Night Lights" the other night. My girlfriend and I had gone out for a friday night on the town. We spent about 5 hours at Dave & Busters - it was my first time there, so I had to explore everything. We played games until my eyes, my arms and my wallet hurt from buying so many damn tokens. Afterwards, we contemplated going to a movie, but declined since it was after 1030pm and we had about an hour drive back to our home-town.

As we were driving home, my GF snoozing lightly in the front passenger seat, I cruising easily along with traffic, I noticed a pair of headlights weaving erratically in and out of traffic behind us. They were travelling at least 95mph down the highway, cutting in and out between cars - often barely avoiding hitting other vehicles in the process. As the headlights came closer and closer to my tail-end, I looked for a place to bail out of the lane, but there was nowhere to go. I had a small car on my right rear-quarter-panel, an SUV about 1/2 car lengths in front of me on the right, and a cement barrier on my left. Instead, I held my course, woke my GF, and hoped we didn't die when I got rear-ended.

What happened instead was like a medical student's dream (especially one interested in Emergency Medicine).

As the headlights flew up behind us, I saw them lurch to the right and a grey Jeep Grand Cherokee (JGC) flew by me, almost clipping my rear end. How it didn't hit the car at my rear quarter-panel, I don't know. Maybe there was a bit more space there than I thought - I'd lost track of that car by now. As the JGC went to the right and by me, he overcorrected back to the left, causing his car to careen out of control. The vehicle ended up perpendicular to the flow of traffic, sliding down the highway and still coming to the left (i.e., toward my car). I had already slammed on my brakes and hit the horn by this time. The JGC continued in its leftward/forward direction, going up on 2 wheels and slamming into the cement barrier.

As if that weren't enough, the JGC then went into a 1-1/2 rollover, ending up on its top and spewing sparks as it slid forward and to the right, back into traffic. How this JGC didn't hit a ton of cars, I seriously don't know. Fortunately, the JGC was the only vehicle involved in the wreck.

Anyways, I had stopped by this time, killed my car, turned on the emergency flashers and began running toward the overturned vehicle thinking (somewhat morbidly), "Oh let there be blood, let there be blood." Does this make me a bad person? Am I something of a monster if I crave blood and maiming like I crave a crushing blindsided blow to a quarterback? Perhaps, but it's what keeps me ticking.

When I got up to the car, my GF was already there (she didn't have to mess with the ignition or the emergency flashers, so she got a headstart). There were beer bottles everywhere and the whole scene smelled like alcohol. The driver (the only passenger in the JGC) had already crawled out the passenger side window, since the driver-side window and the windshield were completely crushed. We ran over to the other side of the JGC and found the driver very drunk, and mostly unscathed (dammit). He was very nonchalantly explaining to us (and everyone else that had stopped) that he was not drunk and that he, in fact, was "awwright." He repeatedly refused to sit down on the side of the road and even let us look him over. Instead, he was hell-bent on staggering back out into traffic to look at his precious pile of scrap metal that was taking up 3 lanes of traffic. BTW, it also happened to be blaring Beastie-Boys "You Gotta Fight!" How apropos when the police, fire, and ambulance crews arrived a few minutes later.

After a few more minutes, we were all cleared to leave, awed not only by the fact that this guy hadn't killed himself, but that somehow, despite the fact that traffic was pretty heavy at the time, he had managed not to take anyone else with him (or send anyone else in his stead, if you want to look at it that way). The truly scary thing is, my GF and I would have probably been the first to go, since he was less than 10 feet from the front of my car when all this happened.

Thank God for small miracles, huh?

Ok, enough for now. I hope you all make your own Friday Night Lights, keep the faith, go after your dreams, and believe in yourselves.

Good night.
Tuesday, October 05, 2004
Before I entered medical school, my idea of a lot of studying was a few hours of looking over notes the night before a test. I refused to study any more than 3-4 hours for any test because I didn't think it was worth it (and frankly, even in nursing school anything more than that would have been a waste of my time. Don't always believe what you hear).

When I was applying to medical school, I knew things would have to change. What I didn't realize was the extent to which everything would change.

For the past 2 years, 3 months and 1 week I have been studying for no less than 2-3 hours EVERY DAY (not including christmas/summer holidays) - this is not counting the increased study time that goes in before tests/shelf exams/boards. Weekends, minor holidays - all have fallen prey to the evil study gods that demand obeisance. That's fine, no problem.

But hell. I need a break. The problem is, I'm afraid that if I take a break I'll get behind, I'll never be able to catch up, that my whole system will fall to pieces and all my dreams will go by the wayside. I have too much vested in my dreams for that to happen.

I realize this is all a bit of overkill, but you get the point. I don't want to have wasted 4 years and roughly 135K by the time all this is through - if you catch my drift...

I think anxiety is a part of the game. I don't know how many of my friends here in school have started taking anxiolytics or antidepressants since first year. More than I can count on both hands, I can assure you. Fortunately for me, I've withstood the onslaught of anxiety and depression better than some and have yet to succumb to medication to ease my pangs. Of course, I've always considered myself thick skinned. Which I guess is why I can give and take so much $h!t.

But back to the point - I need a break from the daily grind. I'm ready for fall break. When do we get that? Just a nice week with nothing to do, nothing to study, no patients to see and no shelf exams at the end... only a mirage in the deserted distance? I'm sure, but it sure is a tantalizing vision!

Christmas can't come soon enough.

Fortunately for me, the block in which I find myself is probably the most intense - Int Med, Family Med and Surgery. Next is Peds and OB/Gyn block, then OMT, PCP, and Psych. Round out the year with some cush... that's what I'm talking about!! I'm ready.
Saturday, October 02, 2004
Lately, I've become stricken with what I can only describe as the "blahs."

I'm sure you've heard of them - when no matter how much (or how little) you sleep, you always feel completely worn down. When no matter how much you have to do, you never want to do any of it.

Yeah. That's me - for like the past 3 weeks.

I don't know what's up lately. I was sick as all hell last weekend. I didn't remember what dry heaves felt like until last saturday and sunday - it had been that long. But it all came back to me in a flash of bad memories.

I wonder if I have mono or something. The thing is, I don't really have any other symptoms - fatigue, malaise... nothing else. No fever, cough, sore throat, weight loss (I wish), chills, diarrhea, nausea or vomiting (except for last weekend), adenopathy, rash... nothing to suggest an organic cause.

And then I was reading about fatigue today in my Blueprints for Family Medicine book - it told me that the majority of fatigue is psychological and stressful situations make one much more prone to be fatigued than not. So, I guess I've diagnosed myself with 3rd year medical student syndrome (3MSS).

I think I might write an article for JAMA or something. Or maybe I'll try to find some tenderpoints and write the article for the JAOA instead - oh wait.. I want people to take it seriously. JAMA or NEJM it is. :)

Not that I have anything against the JAOA - it makes a really good liner for the recycling container. Really, now - if you're going to publish a magazine, at least make it useful.

Ok. I'm done. I'm not feeling too good and my cynicism is showing (stronger than usual). Good night all, have a great weekend.
Tuesday, September 28, 2004
  Hospice (or End of Life Care)
I just came home from my "Hospice day." It is a required day for every student at my school during Family Medicine. Today, I went to one of the 2 larger hospice companies and went around town with a social worker and physician.

It was pretty cool. I enjoyed how upbeat the SW and physician were. It was somewhat depressing when we went into some of the houses, but overall it was a good experience.

For instance, the first stop we made was at a little lady's house just outside of town - about a 20 minute drive from the main office. She had been a home health patient for some time - she had a hospital bed and some other durable medical equipment (walkers, bath chairs, etc) in the house the company had already procured for her. However, her condition had deteriorated such that in the past week she became unable to rise from bed and go to the bathroom, feed herself, or go to her recliner.
She has worsening cardiac disease, and her exercise tolerance has gradually been worsening - now to the point to where she cannot even sit up without becoming short of breath and having to lay back down. She is completely bedridden.

The truly unfortunate thing (as if the above isn't enough) is, that in listening to her family, this woman basically raised her entire neighborhood. She was one who would help anyone that needed it - regardless of whether she had it to give. She lives in a little 2 bedroom house with her sister, her daughter, grand-daughter, and great-grand-daughter. 4 generations in one house. She is so frail - it really was a tragedy to see. And when she awoke, she was sweet as can be... It's just heartbreaking.

So, because of her worsening cardiac condition, she was qualified for hospice care.

If you don't know what Hospice means, let me briefly explain: There are (basically) two trains of thought when dealing with any illness - curative and palliative. They are not exclusive of each other - even when you go to your physician's office for a sore throat he tells you to use saltwater gargles along with the antibiotics he prescribes for you. Both palliative (comfort measures - the gargles) and curative (the antibiotics) together. However, when an illness or condition is terminal (cancer, end stage COPD, Liver disease, etcetera), while the initial stages of treatment may be curative AND palliative (i.e. the physician may try chemo/radiotherapy to cure the cancer or a liver transplant to cure your cirrhosis), if those treatments fail, then sooner or later palliative-only care will take over. This is Hospice.

It is something of a paradigm shift in the way the medical community has thought for many years. For the longest time, any death was deemed a failure. It was not always this way. Death is a part of life, as is birth. One is born, so one must die.. Ashes to ashes, dust to dust. You see the point. What hospice care does is make sure that a patient is comfortable when their time comes. They have hospice aides, nurses, chaplains/pastors/priests, social workers and physicians that work together to help the last days of a patient's life be as comfortable as possible.

How does one qualify for hospice? The general rule is a patient must be certified by two physicians to have less than 6 months to live. This is not a strict rule, but I've heard it said, "If it wouldn't SURPRISE you if this patient were dead in 6 months, you need a hospice referral." Maybe it is really 3 days, maybe it will be a year - but 6 months wouldn't surprise you.

The hospice program evaluates the patient, the patient (or surrogate) must fill out and sign a Do Not Resuscitate order, and the patient and family are educated on what hospice care is, not to call 911 for "emergencies," and how to deal with the upcoming changes. The hospice program sends an aide and a nurse daily, and a chaplain at least monthly. Social worker and physician visits are also at least monthly, or the physician may be reached by telephone for additional orders.

All-in-all, the patient is very well cared for. Hospice care can be done in the home (as is the case of the woman above) or in a nursing home. The only difference is who takes care of the patient when the aides, nurses, physicians, chaplains, and social workers are away.

I think it is a good system. I enjoyed my visit with the hospice program today. I learned a lot about the system and when to refer a patient to hospice. Hopefully my experience shared above can help you as well.
Friday, September 24, 2004
This week has been really boring. One thing I did learn, though, is that I did really well on my Internal Medicine NBME Shelf exam. So now I've received emails from the Dean of Student Affairs and the Dean of the college congratulating me. Who would have thought - me, the person whom they gave an only lightly-veiled threat to dismiss, gets a letter of congratulations from all the big-wigs at my school.

I'm befuddled.

One of my fellow students at my Family medicine rotation keeps giving me the line, "It must be nice to know what you want to go into."

I think it is nice to have an idea at this stage in my "career." Of course, like I constantly tell people, I have a lot more background than most others. I've worked in the medical field for 5 years already - I have a lot more exposure to the different fields than someone who came directly from college (or even someone who had another non-health-related occupation). It isn't fair to compare my experiences or thoughts to someone with no frame of reference. There is plenty of time - the third year is for experimentation with many different fields to find one that fits your personality. The worst thing about it is we have very limited experiences compared to the multitude of specialties available. Going through 8 or 10 different basic fields does not adequately expose a student to the hundreds of fields open for specialization. In reality, all choices are made on faith when it comes to match day. You don't know if you'll like the place you match, if you'll really like the field you've chosen, or if you might want to change in a year or so.

The truly unfortunate thing is once you've started a training program it's very difficult to change without having to start over. I've heard of physicians that finished residency and worked for a year or two before they learned they couldn't stand it and then started over with residency. That is one advantage to nursing, NPs, and PAs. There is no specialization - you can move to another field if you hate what you are doing without any hassle.

I'm done blathering for now... I'll post some more later. Besides, I have to write a synopsis of an Ethics Committee meeting I attended.
Sunday, September 19, 2004
  Some Thoughts
Just a couple of things I've been pondering:

Why are there no prostate cancer prevention walks and/or foundations? Mars candy corporation has recently decided to make pink and white M&Ms to benefit the Susan G. Komen Breast Cancer prevention foundation. I want to know why they don't make prostate shaped M&Ms and money go to research and prevention. Even better, why not have a testicular cancer prevention corporation. Mars can make penis and scrotum shaped M&Ms to celebrate the event.

I love weekends off. Family has the BEST schedule! 8-5, 5 days a week.. And as a student - no pager or calls at night. Life is good.

Of course, I have to lead a discussion on the latest and greatest in hypertension diagnosis and treatment. So I've been pouring over JNC 7 recommendations and emedicine to "refresh" myself on this all to large a subject. Not that I'm complaining - I love learning. Hell, that's a very large part of why I came back to school - I missed it. I really think I am one of those people that could go to school forever. Professional student... If I kept half-time, I'd never have to pay back the loans. An idea is born...

not really.

I've been listening to Opie and Anthony alot lately. They are a couple of shock-jocks that were kicked off the air by the FCC after they were caught promoting a sex event in NYC. They've been off the air for 2 years now, but they are back and will be on XM radio starting the beginning of October. Now I have to get XM so I can listen to them. Or maybe the group of fans that have been digitizing all the old files will continue and I can get them offline. I'm freaking thrilled. I love OnA. Check them out at You can listen to some bits on - check out the MP3 player on the left hand column.

They freaking rock!! Be warned that they are not NEARLY as PC as myself.

You were warned.

I'll write more later. I'm getting dinner ready.
Saturday, September 18, 2004
  Spousal Abuse?
Man Tries to Sue Wife for 5-Day Sex Denial

Fri Sep 17,11:11 AM ET

MADRID (Reuters) - A Spanish man tried to have his wife charged with domestic abuse because she refused to have sex with him on five consecutive days, Spanish newspaper El Sur reported on Friday.

The middle-aged man from Seville -- the city of Don Juan and Carmen -- said her refusals amounted to "degrading treatment" and domestic abuse, a term used more often to describe wife-battering.

The judge shelved the case, Andalusia-based El Sur reported.


I found this entry on Yahoo! News today... I thought to myself, "This must be a sign of the times."

Of course, this would be a pretty nice precedent for all us guys should she be found guilty...

"I have a headache..."
"But honey, it's been four nights. You wouldn't want to reach the 5 night limit, WOULD YOU???"


just kidding.
Monday, September 13, 2004
  3 Years Past
Ok, so this entry is actually a couple of days late.

And there are many people who will think I am a complete and total @ss.

But I don't care...

September 11th has now become the newest (unofficial) commercialized holiday.

Only slightly behind Christmas in popularity, 911 has now been commercialized by the United States to mean, not the emergency response system it was meant to signify, but a day - 3 years ago - that we still mourn over like it was our own baby.

Wake up, people.

Yes, it really sucked. Believe me, I know - I was about an hour away from NYC when it happened. I got called in on my day off to work a 12 hour shift because the hospital had gone on disaster alert. I had no freaking clue what had happened when they called me and told me I needed to come into work. I remember the sinking feeling. But we need to move on.

Yes, I realize some 3000 people died. People die every day. We still need to move on. Tragic or no, untimely or not. We've killed over 1/3 that since in our little "war on terrorism." And that's just counting our troops. Nevermind the Iraqi people we've slaughtered.

Yes, I realize this was an open act of hostility against our country by a group of psychotic religious fanatics. We still need to move on or we run the risk of turning into THEM. Oh, wait - too late. We just don't do it in the name of religion. We do it in the name of W.

Yes, I realize we went to war shortly after this occured. I've said my piece about this. It was a mistake then, it is still a mistake now. We need to withdraw from Iraq post-haste, pour the money we are wasting over there into development of alternative fuel sources and rid ourselves of our dependence on the middle east altogether. If it weren't for oil, would we have ever been interested in that area? No. Why would we need to - they don't make anything but camelshit lotion and, oh yeah, OIL. Remember what I said last paragraph? W. Move on.

We need to silently withdraw from the world. No more troops, no more money. Just close our borders and say, "Sorry f*(kers.. you're gonna have to fend for yourselves for a few decades." Let all the starving Sally Struthers children starve (rather than live in the half-crap-ass existence your 17 cents a month can give them) and all the crazy nut-jobs kill each other. We'll be in self-preservation mode. And if anyone attacks us, we strike back swiftly - with nuclear weapons - and wipe whomever it was off the face of the earth. We're serious when we say LEAVE US THE F*CK ALONE!! No more of this surgical strike bullshit - just take the whole area we think they MIGHT be hiding in and make some glass...

Of course, I might be just a bit extreme.

I'm just tired of W using what is arguably the worst day in our country's history as a selling point for his re-election campaign and Kerry using it as his.

I'm tired of these crying families on the news bawling their eyes out - see a freaking grief counsellor and take Effexor (haha! That drug rep dinner really came in good for something, didn't it?) or something.

I'm tired of continuous news coverage of everything bad that ever happens. Hell, we have continuous news coverage of hurricane IVAN, and it hasn't even reached the US yet. There is a point when we need to turn off the news and look at something real. The news isn't real - it is some producers slanted view of the world.

We need to start reading again. Burn the cable companies to the ground and hand every man, woman and child in the country a freaking book. Tell them to read it (if they even know how to read - nearly 1/4 of high school graduates can't) and prepare a 2 page book report due the next week. If they can't read, shoot them - they've wasted 12 years of the country's resources. That's enough, no more, the store is closed.

And quit buying into all the hype about 911 - 3 years is enough time to grieve. These families have been through enough. Do we really need to drag them through it again every year? Have some compassion, people. Let them heal, let them move on. No more "well, it's been 3 years since we all watched your husband/father/brother/son jump off the 72nd floor to his certain death in order to escape the flames that were engulfing the building. How are you dealing with it? How do YOU remember that day?" How do you think they would be dealing with it when you just recreated the whole thing for them (all the while playing the film on national television)?

I hate newscasters.

I hate politicians.

I hate lawyers.

But I love America. I just wish she'd pick herself up by the boot straps and get back on track. She could be a great nation again if only she'd take care of herself and solve her own problems instead of trying to solve everyone else's for them. All the other countries in the world are big boys and girls - they can play alone for awhile.

What do you think about that?

-- Proud fighter for the highest common denominator!
Wednesday, September 08, 2004
  Letter Writing Campaign??? WTF??!?!?!!?
I've recently been trying to keep more abreast of the news, especially when it has to do with medicine. I think it is important to know what is going on in the world around you - it hasn't hurt that I currently am co-students at my family practice clinic with 2 of (probably) the most political and outspoken people in our class - so I get to overhear a lot of their conversations/debates and occasionally pitch in my 2 cents.

I was surfing the American Osteopathic Association website today (for fun, or something) and came across this. Now, I realize that there is a need to educate people about the Osteopathic philosophy, but is petitioning television shows the best way to do it? I can see it now:

Dear ER executive director,
Did you know that in all your shows' 11 seasons there has never been a DO as a cast member? How can that be, when there are obviously two perfectly legitimate schools of medical training in the US - allopathy and osteopathy? I would highly recommend that next season there be a new crop of students and one of them be a DO student. When discussing a patient with back pain, the student can pipe up and talk about Osteopathic Manipulative Treatment, a hands-on manual therapy founded in the late 1800s by Dr. Andrew Taylor Still.
I feel this would be a great way to get the word out about Osteopathic Medicine and would give your television program a wonderful means by which to educate the general public...

Blah, blah, blah... Does anyone else not see this as a bad idea? I can see it now - that same scenario comes up, and the student is granted the opportunity to use OMT on this back pain patient (which I am sure will need an open thoracotomy any minute for sudden cardiac arrest). Instead of utilizing OMT correctly, the student (who is a bit naive) performs HVLA on the patient which causes paralysis of both legs because (had the student checked more closely) the patient had nerve impingement signs and never should have had HVLA performed - MAYBE soft tissue, muscle energy, or indirect techniques.

What the people who are proponents of this sort of "free advertisement" don't understand (apparently), is that OMT is very rarely indicated in the ED, nor does an EP have the time to perform it.

I realize the idea is a great one - get the name of osteopathy in front of an audience of 40 million all at once. But I don't think it would turn out like they want it to. At the most, they will be able to spend 5-10 seconds on it, then they would be off cracking someone else's chest because they are in asystole (and everyone with asystole warrants a thoracotomy with direct cardiac massage, don't you know). People would be left with a lot of questions - and they would probably look online for more information and be misled or misunderstand what they read. It has too great a possibility to take a negative turn.

Again, I think the idea is good, but the practicality of it isn't. Instead of pouring all this time and effort into trying to get Osteopathy mentioned on some television soap operas, the AOA should spend a little time actually advocating for the physicians it represents, stop opening new schools to further dilute the applicant pool and try something else to educate the public about Osteopathy. Of course, this begs the question: if most patients don't know what degree their physician holds, why do we even care? Why do we have this burning NEED to educate the public and get Osteopathy in the public eye if it doesn't really matter - we are equal in every way to allopaths (some would argue better), we have every right to practice in any specialty, etc. Why do we need to pick little stupid battles like this? Why don't we work on getting equal practice rights in every country in the world rather than argue where we're already equal. What if I (hypothetically) want to move to France and practice after my training is over? Ooops, I can't - DOs don't have full practice rights there..
Sunday, September 05, 2004
  In Focus
I don't know if anyone else keeps up with medical news regularly (other than what they show on the nightly news), but I am a fan of medscape dot com. I have been a member for roughly 7 years and have long used the resources available there. In particular, however, I am a fan of a certain EM resident that writes articles for the site. The reasons should be pretty obvious why I'm such a fan.

He is a great writer, and always seems to find subjects that are very touching for me. For example, his latest article is about how often the medical system fails those people that just "fall through the cracks," so to speak. It also speaks to how the medical administration is frequently responsible for the rift between physicians and their patients, and how, in EM, it is difficult to help mend that rift.

Physician-patient relationship. That is a term often thrown about lightly in school, but never really defined (so to speak). The easy definition would be superficial and would be the fulfilling of the patient's needs on a particular visit. This is often the sense of the term used in the ED (being an urgent care setting).

However, in the more encompassing definition (i.e. the one I am learning about now on my Family Medicine rotation), it means much, much more. It is knowing not only the patient, but the patient's parents and children - and sometimes their grandchildren. It is calling them by their first name when you first see them, not checking their last name as you walk in the room so you'll remember. It is being involved in their lives - seeing them in church, in the mall, at the grocery store - and always portraying the role of the physician-teacher - for that is what we all should strive to be.

This month has opened a whole new dimension of the physician-patient relationship for me. Being an integral part of patients lives and actually making a difference to them.. now I can see why Matt M so much desires to enter this field. It is actually much more appealing than I ever dreamed.

I'll be sure to keep you updated with more as the 2 months go on. For now, let me end with a story to emphasize my point:

A 41 y.o. WF came into the office last week for a medication refill appointment. How boring, you might say, right? Med refills? Come on!?! But every visit is a chance for patient education and to see how everything is going. Knowing this patient has a history of HTN, smoking, Hep C induced liver failure and bullous pemphigoid from reviewing her history, I armed myself to go talk with her.

The first thing that I noticed when I entered the room was the pervasive smell of cigarette smoke. My eyes started watering as I entered the room, it was so strong. But I persevered, introduced myself and clarified that she was, in fact, here only for medication refills. I talked with her for a while about how she had been: what has her BP been like, has she had any outbreaks of her pemphigoid, etc. I broached the subject of smoking with her briefly - she said she had considered quitting, but didn't think she could do it unless her husband also agreed. So I spoke with both of them briefly about smoking cessation and encouraged them to quit. I then proceeded to a brief physical exam. What I found would change the course of the visit.

On every patient I see, I always do a cardiovascular, pulmonary, abdominal and brief extremity exam - no matter the reason for the visit. Just seems prudent to me. As I was performing the pulmonary exam, I noted pretty widespread expiratory prolongation - an early physical finding in COPD. I asked the patient exactly how long she had been smoking and how much: about 40 pack-years is what it came out to be. I also asked her whether she frequently became short of breath or wheezy - she said "yes, how did you know?" So I discussed the physical findings I discovered on her exam. As I explained what I found and what the possible implications were, a look of fear and understanding came over her. She said "my father and brother died with emphysema from smoking.." and became very quiet. I explained that these are early findings and if she quits smoking now, the damage will stop - but cannot be reversed. She turned to her husband and said "I need to stop now."

Just that small physical finding - something one might miss if they weren't paying attention - may make such a huge difference in the patient's life (if she, in fact, chooses to stop smoking). As she left with her prescriptions, I felt a small amount of joy - thinking that I may have actually helped someone that day.

The smallest things can sometimes make the largest amount of difference: a 5 minute physical exam may change the course of a woman's life.

Saturday, August 28, 2004
  Donnie Darko
I watched this movie the other day, and Oh My God! It is hilarious. If you haven't seen it, they now have it at blockbuster and you MUST RENT IT!

Basic synopsis: Donnie Darko (yes, that's his real name) is a paranoid schizophrenic teenager (aren't they all?) who is led on various adventures by his "imaginary" friend, Frank-the-6-foot-tall-rabbit. The whole movie is about the hijinx he gets into. Its somewhat dark, but is still very funny. For mature audiences only, please. No 10 year olds...

Otherwise, this weekend has been completely relaxing. Took the departmental exam on thursday (which was exactly what I expected it to be - since they gave us the questions) and then the medicine shelf on friday. We'll see about that one - I had a pretty good feeling about it, though. Hopefully I'll score well and not trash all my hopes.

Now, I'm in the process of re-vamping my curriculum vitae and writing a personal statement so I can start to get letters of recommendation from my clinical preceptors. I know, I know.. it's too damn early for that, but I think getting them early is better. Especially since medicine is one of the big-hitters as far as letters go. Hopefully I did well enough to get a decent letter.

For EM, it is recommended that you have two letters in the S.L.O.R. (Standard letter of recommendation) format - ingenious name, isn't it from clinical EM faculty (preferably someone like Rosen or Tintinalli, but anyone from a residency program would do) and then at least another from another "relevant" clinical discipline. The problem is, what discipline isn't relevant to EM? I haven't found one yet - nor can I think of one off the top of my head.

So, I'm spending hours in front of my computer, trying to remember everything I've ever done in my life that might pertain to residency applications (or medicine in general) so I can put together a C.V. The next task is to try to figure out what I want to say for my personal statement. I hate writing those stupid things - but supposedly they are OH SO IMPORTANT when it comes to residency applications. How ridiculous. I thought this was about medicine, not journalism. Maybe someone can clear that up for me. And don't tell me that "a well written and poignant personal statement can catch a program directors eye." That's a cop-out, and this is about realism. So, what exactly is the purpose of a personal statement?

I suppose it is to tell your story. But what if your story is boring: You've worked in the ED for 5 years and you know you like it and you know that EM is a good fit for your personality type.

That's it. I guess my personal statement will be pretty short. You've seen it here first, folks!!

Oh well, I guess I'll need to come up with something more lengthy than that. Besides, I don't know how much residency committees will like me telling about my experiences in the ED as a nurse. I guess we'll have to see, eh, since that's all I have right now.
This is an online accounting of my experiences as a 3rd year Osteopathic medical student. The words here may be blunt and not altogether P.C., but I was never really one for political correctness. Regardless, get ready for the wild ride that is "Medical School - Year 3" Sounds sort of like one of those TLC series' doesn't it?

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