It is no secret that I dislike research. And yet, I must admit it is slowly starting to grow on me, especially when I see physicians get peer recognition for such stunning work as this:

The role of sexual intercourse in the etiology of carpal tunnel syndrome

Zenian J.
1341 Portsmouth Ave., Westchester, IL 60154, United States.
The etiology of non-occupational carpal tunnel syndrome is not well understood. It is proposed that carpal tunnel syndrome can develop during sexual intercourse when the hands become repeatedly extended while under pressure from the weight of the upper body. Of the eight risk factors associated with non-occupational carpal tunnel syndrome, age, marital status, pregnancy and use of hormonal agents can be explained by changes in the frequency of sexual intercourse. On the other hand, obesity, macromastia and large chest circumference can be explained by the increased pressure imposed on the wrists by the heavier upper body associated with such conditions. The bilaterality of carpal tunnel syndrome can be explained by the fact that both hands are needed to support the upper body during sexual intercourse. A parallel decrease in the frequency of sexual intercourse and the incidence of carpal tunnel syndrome between the sixth and the seventh decades of life suggests a possible cause and effect relationship between sexual intercourse and carpal tunnel syndrome.

Copyright © 2009 Elsevier Ltd. All rights reserved.

PMID: 20060652 [PubMed - as supplied by publisher]
Med Hypotheses. 2010 Jan 7. [Epub ahead of print]

And this article doesnt even take into account injuries from auto-erotic repetitive motion

Am I keeping to my once a week posting, or have I already broken my resolution?

In either case, it has been a busy busy week. I have been fortunate enough to perform two lumbar punctures on patients and it wasnt anywhere near as scary as I thought it would be. I find that happens a lot in residency...I spent all medical school getting all psyched up about one thing or another that I thought would happen when I became a real doctor, and then it actually happens and it turns out not to be anything I can't handle.

But I digress. My very first lumbar puncture ever was on a elderly (surprise surprise) gentleman who was pretty much comatose by the time he came in. The ED doc had stopped by the workstation to talk with the attending and asked if there were any residents around who wanted to do a procedure. As part of residency, we have to do X number of procedures like paracentesis (draining belly fluid), lumbar punctures (spinal taps) and ABG (drawing blood from arteries) to ensure that we are capable to provide any kind of care at any time as part of the diagnostic workup. So off I went to do the procedure with the ED doc providing a watchful eye and a guiding voice as I did my very first solo spinal tap.

The gentleman was rolled on his side and placed with knees to chin, balled up in the fetal position as tight as the nurse could make him. This helps curve the spine and presents the maximum surface area available for me to slip a needle in between. This is good because the last thing you want to do is miss the spinal fluid and accidently stab the spinal cord. Then after feeling for the anatomical landmarks, the spot was marked and confirmed by the ED doc and I numbed the area and in I went. I'm told by friends who have had it done that it is a fairly painful procedure but this gentleman didnt even flinch, which told me just how sick he was. Fortune smiled upon me however and I got it on my very first try...a gentle popping sensation and sound as I passed through the vertebral colum, and when I withdrew the trocar (guideline inside the hollow needle) a clear fluid came dripping out. I collected in into 4 small vials and then sent them off for studies to find out if he had an infection in his spine.

Now quite often interns will cause a "traumatic tap". This means that they dont find the right space on the first try and the first vial will have a high degree of red blood cells, and thus be pretty much useless to the lab. High degree is 60rbc or higher. COnversely, there is also a "champagne tap" wherein no rbc's are seen, and the csf (cerebro-spinal fluid) collected is clear like champagne. It is also called that because if you actually achieve fewer than 10rbc's, or a totally clear tap, the attending who supervised you is supposed to buy you a bottle of champagne. So my very first one had 22rbcs in the field...too high for free alcohol, but a pretty respectable number for a first try by a rookie.

....

About three days later, I have an 80 year old woman with severe dementia who initially came in with a pneumonia, but has altered mental status a little more severe than could be explained by her dementia alone. So infectious disease specialist is consulted and recommends a lumbar puncture to rule out meningitis (inflammation of the spinal cord). No ED doc around this time to help, and my resident has clinic. She offers to find a third year to supervise me, but reassures me that, "you have already done one, you will be fine" The third year who is there to supervise has only done one in his three years of residency.

Let's pause there for a moment, shall we. The person supervising me during this procedure will have less experience than me by the end of the procedure. Ah, residency.

Carrying on. Unlike my first patient who was knocked out 6 ways from sunday, my current lady is demented, angry, fidgety, and has a mouth like a sailor. It takes 2 nurses to hold her in position and this time I am doing the whole procedure from memory, with minimal input from the supervising resident. (which I am okay with, i just didnt want to be alone to do this) I found the landmarks on my own, I cleaned and draped the patient and even had to use my "doctor voice" to quiet the lady down because all her moving only prolonged the pain and procedure for the both of us.

Unfortunately, the first attempt, I missed the landmark completely, placing the needle about 1inch too high...whether because of the difficult behavior of the patient or my own inexperience is anyones guess.

Rallying to the fight however, I knew my mistake, and just like in showbizness, you never let them smell the fear. I simply told the patient that I had to do the procedure again and she would have to stay still this time. I then re-anesthetized the same area 1 inch lower, and set back to work...and a short time later was rewarded with spinal fluid. I had guessed my mistake correctly and adjusted myself accordingly with no one other than myself (and the resident) the wiser. And for all that the rbc's in tube 1 was only 61, with the patient not suffering a post-lumbar puncture headached that commonly occurs after traumatic taps.

So while my second attempt did not warrant a bottle of champagne, I still celebrated with a glass of beer for a job well done. One of the procedures that had frightened me so much in medical school, the thought of putting a needle into someones spine, had succesfully been done by me twice in one week on an easy and a difficult patient and both times I had achieved success.

Looks like I'm starting to get the hang of this whole doctorin' thing after all

First and Foremost, Happy New Year to everyone.

Before I begin my yearly review, let me welcome you into the new year with my favorite toast

May the best you've ever seen Be the worst you'll ever see; May friends never leave your homestead Wi' a teardrop in their e'e. May you all keep hale and hearty Till ye're old enough to dee, May you all be just as happy As I wish you all to be

And now, my yearly tradition, even as my regular blogging has fallen somewhat by the wayside

PART THE FIRST

Go to the first entry of each month for the last year
copy and paste the first and last sentence of each of those entries

January
Once again for kicks and giggles, I am enrolled in a medical ethics course...as such, I am obliged to read up on the principles and post discussions in response to current event...
...lets see how we do, shall we?

February
I am back in Chicago after a 2 month absence. Nothing has changed, and yet everything is different...
... So in my remaining time here, I will endeavor to revisit a few old haunts, and explore as many nooks and crannies as I can before it is once again time to day goodbye.

March
Ah, the beginning of the end as Istarted my last rotation as a med student ever today, Child Psychiatry...
...Also, if you have ever wanted to hear Barack Obama say the words "ignorant motherfuckers" you need to go here, right now Barack Obama Cursing

April
I have been back home for less than a week, and already I am beginning to remember why it was so nice to be 3000 miles away with a place of my own...
...I hope I can pay off enough of my debt to move out sooner rather than later. It's a lot easier to get along with my family when I have somewhere I can escape to if I need it

May
Hey folks, while I prepare for my trip (first one to give me a cool nickname like Indiana Jones wins a prize!) Here is some information about the swine flu...
...My grandfather always told me we would see a black president when pigs fly...and 100 days into office for Barack Obama...swine flu

June
Thanks for all the birthday wishes, I spent my special day touring the pyramids, pretending to be indiana jones/brendan fraser in the mummy, and getting drunk on the train to Aswan...all in all, a rousing success....
...ncidentally, I think my stomach has more jetlag than my sleeping time, as I have been getting hungry at odd hours

July
Leaving Egypt behind, I had to cross not a desert, but a sea, to reach Jordan...
...nd I wasnt going to be the one to find it. I had enough on my plate, and my trail was leading me ever closer to the holy grail. I could tell I was close, for the next stop on the tour would be the Red Rose City

August
Okay, well not really. More like 2 weeks of night, followed by 2 weeks of day and then back to the reverse. But you will have to forgive me a little drama as I prepare to embark upon the REAL beginning of my residency...
...Join me at around 3-4am for the next several weeks, and we will find out what those are together.

September
I just pronounced my first patient.Specifically, I pronounced him dead. shuffled off this mortal coil. An ex-human, as it were...
...After all, I still had another 10 pages to return, and the night was just beginning..

October
An orca fat patient (BMI 40) came in for diabetes and sleep apnea...
...the child screams "no, not in the butt!!" the father replies " yeah, you and your mother both"

November
The numbers on the clock read 3:30. 30 minutes until I am protected from admissions, 90 minutes until I get to go home...
...Next time, I will be much less hesitant and once again, I will go for the throat!

December
Currently I am rotating in the coronary/cardiac care unit, or ccu. I dont like it...
...Oh well. Happy Holidays.

And with that my new years resolution is to improve myself in every conceivable way

what's yours?

Okay, I admit it.

Much as I complained and whined about ccu, it has already made me a vastly better doctor in terms of my knowledge base and how confident I feel in dealing with patient medications. It happened so gradually I didnt even realize it.

Not even one month ago I would make a note about medications I though should be changed and wait til I could bring it up in rounds phrased as a "maybe we should...what do you think?

Now I am making changes as I see fit in the mornings, and present on rounds with here is what I have done in reaction to my findings. And if I erred (and sometimes I do, but less often than I was worried I might) I am corrected and learn something else from it. I am finally starting to stay ahead of my patient's findings instead of always chasing after labs. I am beginning to learn to anticipate and develop my clinical judgement. Which is a nice holiday gift

Which is good because I am working on both xmas and new years. But at least I am back on R service and have once again found my small joys. It makes a difference

So xangaland...wishing you and yours a happy holiday season and a merry xmas full of all the small joys you can find. Hope they have added up to a great year!

-Dr J.

A short list of the people who helped influence my medical personality along the way. Even though I doubt any of them will ever read this, I wanted it set down somewhere so I dont forget. And now, in no particular order

Raj Kalsi: My resident during my 3rd year trauma surgery rotation at Masonic. Hated every moment of trauma, loved the team. Thank you for not only treating me like an equal instead of your scut monkey, but of showing me the importance of documenting documenting documenting everything you think say or do with the patient for a medicolegal standpoint, and of how to befriend the nurses so you dont get quite as many bullshit pages overnight. You showed me how to make even terrible rotations or parts of rotations fun, and are one of the residents who I have tried to model myself after

Jonathan Davidorf: Not only one of my wonderful physicians, but one of the ones who had a pretty significant amount of influence on my remaining determination as I powered through. You helped show me what the business and private practice side of medicine is like, and took a chance on a young college premed student looking for some experience, and turned him into a trained opthalmic surgical technician with a skillset and ability to learn from my mistakes and criticism. While you may not always have been the best boss, I would still send my family and friends to you as an amazing doctor

Michael Lotke: For a while you had me seriously considering pediatrics as a field because you made it so entertaining. You showed me that it was okay for a physician to have outside interests like performing, or cooking, or whatever else helped to keep me sane outside the job. Pimping was never about making the student feel bad, it was about engaging their curiousity and getting us to think before we acted. You were also one of the few physicians who took the time to teach us as students what to do when patients died: how to talk to the family, how to take some time for yourself to let it all sink in, and how to accept that it is going to happen and its just another part of the job

Charles McCormick: My first real medical school professor, you taught me physiology from the old school busting out a dry erase pen and light board while everyone else was in the world of powerpoint and electronic aid teaching. One of the few people who genuinely had an open door policy, I never felt any hesitation about wandering in and chatting with you if I had a question or just wanted to say hello. You helped show me that teaching could be as important as learning, and both could be enjoyable when done by someone interested in the subject material

Dad: One of the only non-medical professionals on this list, you supported me from the beginning without ever pushing me into medicine. I got the feeling I could have been painting on a street corner, making soup in culinary school or doing research to cure cancer and you would have been equally proud. While you did not live long enough to see me make it all the way into med school, you saw me slip in the back door and a desire to make you proud after your death continues to push me to constantly improve myself, and helps keep me honest. You showed through your action two of the most important lessons I probably carry around in my head as a doctor, that a person is only as good as their word, and just because you dont like someone is no reason to be rude to them, and if that doesnt sum up how I get through most days, I dont know what does.

The List goes on, and this entry was more for me than for anyone else reading, but in case you guys were wondering what shaped me, above is a brief but important subset of people who had a pretty big hand in it.