One of the things it's hardest to get used to about #residency is never knowing what happens to most of the patients. I switch rotations, or they switch services, and there's no system to know what the result is.

Not that I want an endless daily report on everyone I've ever treated, but sometimes, a couple of days or weeks or months later, a patient crosses your mind, and you don't remember the name, and you don't have anyone to ask, and so you just never know.

Maybe you see them again, months later-- it happens, more than you think it would-- and they're back on your service, so you end up seeing how they're doing-- but, usually, you never have a clue.

You're such an important part of someone's life often for such a very short time. It surprises me sometimes when I realize I care. When someone happens to have some quality that reminds me of someone in my family, or is in a situation I can empathize with, or we just have that little connection that makes it feel like more than just ticking the boxes each day and writing the note.

But, far too often, it just feels like an academic exercise. I wonder what's wrong, I wonder what the plan is, I wonder if they'll get better. The same way someone might wonder how their science fair experiment will turn out. Oh, look, giving a sedative does exactly the opposite of what I would have expected! Interesting! Hope to remember that next time. Maybe I should write it down...

I walk into the ER and notice a young couple at opposite sides of the room, neither one looking at the other, eyes downcast, the man occasionally reaching for his genitalia, the woman nursing a black eye. Seems like a fairly straightforward case and I find myself wondering why I got the call from the ED doc to admit to medicine.

Turns out the couple had been celebrating an occasion, lets say an anniversary just for the hell of it. At the fancy restaurant, the woman decided to slip under the table to give her beau an appetizer before the main course, as it were.

Of note, her past medical history is significant for seizures which have been well controlled on anti-convulsant medication. Of more significance, she opted not to take her medication this evening as she knew she was planning to have alcohol and was worried about possible interactions.

So there she is, fellating her companion when all of a sudden she begins to seize.

Kindly reread the above sentence.

The man, on the receiving end of a ooh, ooh, OW reaction, does some quick thinking and calculations and realizes that he is poorly positioned to be involved in her seizure. After trying once or twice to forcibly remove her head, he does the only thing he can think of to save his member and punches her right in the face. At which point he then goes to obtain assistance for his significant other with what had to be an elaborately concocted cover story.

End tally:

1 male with a lacerated member

1 female with post ictal confusion, remembering only that she went to a restaurant and is somehow now in an emergency room with a black eye

So, my questions to the modern gentleman

1.Does this qualify as the only acceptable excuse for hitting a woman?

2. What are your odds of the male counterpart of this dynamic duo suffering PTSD-no honey, lets just cuddle tonight, no BJ's necessary

"I started feeling the pain right after I ate lunch. So I think it was the sandwich."

"You had a significant heart attack. The fact that you were eating a sandwich just prior is a coincidence."

"Well, I think the sandwich caused it."

"You have a completely blocked vessel leading to your left ventricle."

"It's the sandwich."

"The sandwich is not blocking your vessel."

"What if I didn't chew it completely?"

"Food doesn't get swallowed into your blood vessels. There's medication we can give you to help your heart, but I need you to understand, this is a problem that's been building over the course of years."

"I did not have a problem until I ate the sandwich."

"You didn't have any symptoms, but the blockage was building. Your heart was not in good shape-- and now, post-event, it's in worse shape. Which is why we need to start you on medication."

"I don't care what you say, it was caused by the sandwich."

"That's fine if you think it was caused by the sandwich. Even if it was, it doesn't change what we have to do going forward. You need to change your diet--"

"Of course. No more sandwiches."

"Well, it's more than that."

"No-- it's the sandwich."

"Fine. No more sandwiches. Your heart attack was caused by a sandwich. And I'm writing you a prescription for three anti-sandwich pills that will help counter the effects of past sandwiches."

"But if I don't eat anymore sandwiches, I shouldn't take the pills?"

"No, you need to take the pills either way."

...

"Then how is this helping with the sandwich problem?"

Dr. J: "This is Dr. J, returning a page."

John: "Hi, this is John Anydude. You saw my girlfriend a few weeks ago for a left arm injury? She had a lot of trouble using her arm? I was with her at the appointment?"

Dr. J: "What can I do for you?"

John: "Well, she's getting a lot better, like you said she would and, um, I..."

Dr. J: "Yes?"

Mike: "Is there anything that might, like slow down her recovery? Not a lot, 'cause she's my girlfriend and all, but maybe just make it take longer?"

Dr. J: "Um, we're trying to get her better."

John: "Yeah, but she can use the arm for almost everything now, and when it was really weak she had me come in the shower to shampoo her hair for her, and that sort of got things going if you know what I mean..."

Dr J: I see you've lost almost 15 pounds since your last visit-- that's great! You're sticking to the diet we talked about?

Eaty McEaterson: Yep. But, doctor, I don't think this is healthy for me."

Dr J: What do you mean? Your blood pressure is lower, eating healthier and losing weight is going to be good for your heart failure and diabetes, it'll help your back pain, you're really doing great, I'm very proud of you."

Pt:But my foot's been hurting, and I think its because of the weight loss."

Dr J: ???

Pt:It used to be cushioned with all of this fat. Now that I'm losing weight, there's less cushioning, and when I walk, it's really the foot that's feeling the weight, without that cushion. I feel it all over. The fat made things soft. Now everything hurts

Dr J: That makes no medical sense, let me take a look and maybe I can get some xrays if you have a sprain or fracture or something

Pt: But now there is less fat to absorb the radiation and I am at a higher risk for cancer

Dr J: *curls up into little ball and cries*

What you say: "I take my pills almost every day."
What we hear: "I almost never take my pills, and probably don't even know where they are-- if I even filled the prescription to begin with."

What you say: "I think I followed up with the specialist, yeah."
What we hear: "I did not follow up with anyone, and only now remember that I was supposed to."

What you say: "You told me not to eat anything before I came in, so, yeah, I basically didn't eat anything."
What we hear: "I had breakfast, but I ate it quickly."

What you say: "I probably don't exercise as much as I should."
What we hear: "The walk from the parking structure to the clinic is the longest walk I've taken since my last visit."

What you say: "Do I need to get that test done today, or can it wait?"
What we hear: "Am I actually going to drop dead on the way out of the clinic, or can I forget all about this, forever and ever?"

What you say: "But what I really want to talk about is this other symptom that I've been having for the past twenty years, unchanged."
What we hear: "Here is an irrelevant distraction I'm going to mention, that's been going on so long that if it were important, it would have killed me already."

What you say: "And I read online that--"
What we hear: "I am now going to prove that I have access to the Internet."

What you say: "No, that's okay, I'll call for a follow-up appointment."
What we hear: "Goodbye, forever."

Doctors are a lot like mutants...there are a lot of us out there among you, we each have our own special abilities, we feel like no one but others in our situation can understand what we have been through and we are feared and distrusted by a lot of the general public who seems to think we have abilities beyond human ken

Sadly the resemblance ends there or I would be liquifying stuff with my mind all day long. Of course just like Professor X's gifted, we all went through a special school where we learned to develop our burgeoning abilities as well. For some of us the mystique didnt last and we left for greener pastures. The learning process managed to turn others of us into beasts, although we manage to retain some of our human nature. The rest of us may have remained unchanged on the outside, but the havoc within us could lead to screaming banshees at any moment and magneto could...you know what? I think I lost my metaphor somewhere, let me know if you see it around.

More to the point, July 1st is the medical new year.  Medical interns begin their journeys into the real world of clinical medicine, journeys that started during medical school but become much more real when they sign their own orders in a chart. This is the first week for all these new interns. So New interns, I was once in your shoes, and will be again when I start fellowship next year. Here are a couple things to keep in mind:

1.Embrace your fear.  You have good reason to be scared.   You are directly responsible for the lives of others.  These others are very sick, or they wouldn't be in a hospital.  But remember that you aren't alone.  Your colleagues can and will help you, and you can help them.  Support each other.  

2.Never be afraid to ask for help, but when you call, have your information in hand; anticipate questions.  If you don't know what to do about a cardiac dysrhythmia, make sure you have an EKG and have ordered some labs before you call the cardiac fellow.  It will save you time and embarrassment, and will get the patient help more quickly.

3. Sleep when you can.  Sleepiness harms both you and the patient.  I cannot emphasize enough the value of sleep.  Go to bed early, nap if you can.  If you're too tired to drive home, don't

4.There is not a single tone on your pager that will not make you hate all humanity at 3 in the morning. Sorry.

5. You now  live behind a magic curtain of people’s expectations and perceptions. You are more than just you now, you are a symbol...like Batman, or Captain America. Try to live up to it, but give yourself some secret identity time too.

-Dr J, superhero at large.

In just a few days I will begin my final year of residency. Starting once again, on night float :-/ Ah well, what can you do. It seems strange to think I have been jotting down intermittent thoughts here since my pre-med days, all the way up to now, when I will be finishing up residency and beginning a fellowship. I look back at myself and sometimes wonder how I had the dedication to stick it through. There is never any hint of doubt in my posting that being in medicine is what I wanted to do, although there is lots of doubt about the path I thought I could or would take.

And yet despite all that I made it. Muddled through step 1,2,3 of the usmle, obtained my medical license, my DEA card, my NPI number, more letters after my last name than anyone really cares about and I still have another 4 years of training.

That said, This friday, when I start as an r3, no matter how stressful any given patient or night may become...

...I made it.

Video link courtesy of one of my interns

-Dr J

On yet another day of continuity clinic, I was expecting more mundane blood pressure and diabetes follow ups, another visit from my fibromyalgia patient, and possibly some genital related question. All in all, pretty standard fare.

Hmmm...25 year old here for yearly physical, no past medical history. Oh good, I figured, this wouldnt take long...go in, listen to heart lungs poke around stomach and reflexes, send him on his way with a clean bill of health.

Pt: Oh doc, I had a couple questions while I am here, the last doctor wasnt really able to answer them to my satisfaction and just sort of brushed me off.

Dr J: alrighty, fire away...

Turns out that the patient had had a 15-20 pound weight loss in the last two years, most likely because everytime he ate anything, he would throw up about 20 minutes later. He said his previous physician 2 years earlier told him he was a healthy weight and not to worry about it. Now, he was still a healthy weight, but I asked him, if he threw everything up, was there any pain or difficulty with swallowing, and he denied any. Then I asked him what foods if any he was able to keep down...and he mentioned his diet consisted entirely of fruits and vegetables

At this point, the hamster wheel in my head began to spin...

Upon further review I learned that the foods which tended to make him sick following their consumption included spaghetti, rice, milk and cereal, and occasionally alcohol, specifically beer

Noticing a pattern? all grains. all gluten containing foods.

So I sent him off to GI after ordering a comprehensive celiac disease workup including an iron panel and IgA antiendomysiall antibody and Iga antitissue transglutaminae. In earlier times, an antigliadin antibody would have been ordered as well, however that has been found to have a lower sensitivity. It came back positive.

What makes this patients case so exciting (at least to me) is that he had no family history of any digestive diseases, and was from an ethnicity in which this particular disease is fairly rare and unlike the majority of my celiac patients who show up with the diagnosis already made, this was somebody who had absolutely no clue what was going on with him.

Sure it was a fairly textbook presentation in terms of symptoms, but had he not seen me, he could have gone on for who knows how many years with the same problem, just being brushed off until some other doctor picked it up on a whim.

My patient

My knowledge

My Diagnosis

It was one of those moments that helps to remind me why I went into the field.

I havent done anything educational here for a while. No, it has just been comics, and occasional mentions of my travels (still have a ton of australia posts to do) or my love life (spending time with girlfriend takes precendence over updating the intarwebs). Medicine works its way in every so often as well.

SO today, I am going to learn you all good about some handy dandy food products you can use for medical conditions. Please note, none of this constitutes actual medical advice, as for all you know I could be a cabbage farmer in Siberia (bUy our cabbage, it makes you strong like bull!)

Cranberry Juice:

This is the one you probably all know about already, but a recent review of the medical literature shows that cranberry juice may actually be helpful for preventing UTI's in woman who expereince them recurrenctly

Coffee:

Caffeine is structurally remakrably similar to theophylline, an old-timey treatment for asthma little used today. Although we have access to beta blockers and inhaled corticosteroids, should you be on vacation and suffering from an asthma attack with no nearby hospital and no meds on hand, downing as much coffee as you can should help ease your breathing while en route to proper medical care

Honey (yes dear?):

Yet another cochrane study although of much lower quality showed that honey may be better than placebo in relieving the pain of partil or full thickness burns...so next time you have a sunburn, dribble some honey on it. Also effective? the tannic acid in lipton tea bags...slather yourself in a little english breakfast and watch as that burn fades away!

Vinegar:

In one that is close to my heart, especially during the summer season, vinegar should be liberally poured over any jellyfish stings, as it will prevent the undischarged stinging cells from firing. Contrary to popular belief, urinating on it will not work and will just embarass you and whoever you are urinating on...unless you are into that sort of thing, which is an entirely different problem.

Bacon!:

Myiasis is tissue infestation by fly larvae (Order Diptera). There are different types of cutaneous myiasis, including wound-infestation, migratory and furuncular. Furuncular myiasis results from the fly larvae penetrating the skin where they feed in the subcutaneous tissue. The larvae still need to pop up for air now and then, so seeing a wriggling white thing with black “eyes” (respiratory spiracles) poking out of a skin lump is a dead give away. There are two important types of fly that cause furuncular myiasis. The human Bot fly (Dermatobia hominis), found in Central and South America, and the Tumbu or Putsi fly (Cordylobia anthropophagia) from Central and Southern Africa (plus at least one case from Portugal!).

The furuncles are left covered with bacon fat. This encourages the larvae to exit the skin, either due to suffocation or an attraction to bacon. After about 3 hours the bacon fat is carefully removed with forceps at the ready to help fully extricate the larvae

So if any of you were planning a trip to central america, or africa, keep some bacon handy, it might just prevent some uncomfortable furuncles...plus you will be able to eat bacon!

So there you have it, dont say I never taught you anything

-Dr J