Finally after two weeks of trauma, I have been able to begin general surgery…from here on out i am down to my last possible rule in/out career choice. After being on call all night (and getting a ludicrous 6 hours of sleep-clearly not a trauma call) I was able to observe a radical mastectomy for breast cancer. It was frankly, how do you say, amazing. Only two relatively small incisions were made and from there the remainder of the breast was just electrocauterized out…the subq, the fascia, everything cut throught until nothing more than a fatty lump was left behind for pathology to examine and a number of horizontal mattress sutures were place to hold closed the giant gaping hole in this persons chest. It basically rekindled the interest in surgery that trauma had been sucking out of me. Lets see how the next 6 weeks go, shall we?

And speaking of beginnings…

CONTINGENCY PLAN

Three-PROGRESSION

It had been almost one month since the superbug had finally made its way into the hospital system. And the long and short of it wasnt good. None of the patients had technically been cured. Oh sure, on a few of the younger ones the fever had finally broken, but all that seemed to mean was a few seizures and neurological damage leading to an altered gait, decreased mental status, and that damn persistently low tempurature. It was enough to drive any resident mad, forget about a medical student. The entire SICU and MICU wings were filled with patients in isolation from the new superbug, and new cases were coming in all the time. In fact, Josh was becoming uneasy in general about this epidemic

The majority of new cases presented with in with bites or scratches. Oh sure, every individual case sounded reasonable, especially considering the number of drunks admitted. A cut on the face here, a minor bite on the shoulder in a barfight there, but nonetheless a disturbing number were being admitted with rule out eikenella infection per ID (infectious disease) on their differential.

And the presentation didnt help. An infection that intially had its greatest toll on the elderly and infantile, that led to a progressively decreased tempurature and deteriorating condition, ultimately only semi-resolving with seizures and an altered gait and mental status. Since this infection fell under the authority of the CDC, universal precautions were of course being followed and the majority of infected remained in isolation, but with no way to tell how the infection spread, it was only a matter of time before someone outside contaiment became infected, or, even more likely, an unknown infected in the community spread it to others

Under any other circumstances, any budding infectious disease student would be creaming their pants. But there was something about this infection that seemed just a little too familiar for Josh to write it off as inconsequential. So he began sending out a few emails to friends here and there, mostly with subjects of just catching up, and the occasional advice thrown in…

“Hey amigo, how you doing…haven’t written in a while, so thought i would say hi. What you been up to? Superbug all over the place in your town too? Well you know what they say about good health and exercise right? You should look into getting a bike or something, give you an excuse to stop watching all this depressing news. Or maybe take up a hobby…fencing, shooting, martial arts. Anyway, let me know how things are going your end…”

…

Each week, things seemed to get a little worse, and the healthcare community less able to handle it. Most of the superbug patients now had to be restrained, and the young and otherwise healthy were becoming infected as well, and still no one knew how. Josh was checking Mr Greenbergs;s vitals religiously. His tempurature was into the ranges of hypothermia now, and yet his pulse and saturation and blood pressure were still those of a normal healthy adult. At the same time, the gentleman in the wheelchair, who had been admitted the same night as Mr Greenberg required restraints and a sitter, having thrown himself out of the bed several times in an attempt to attack hospital staff. He had even managed to bite one of the nurses, who was on enforced leave given the situation.

More and more in the recent weeks, a thought had begun to tickle at the back of Josh’s mind. Nothing he had chosen to articulate to others, but a nagging feeling that had caused him to double check the tire pressure of his bike, buy extra canned food, and “borrow” medical supplies at the end of shifts. The more he sat and joked about it with friends and family, the more uneasy he began to feel. This disease just seemed too predictable, despite the fact that nothing was known about it. It was almost as though he had encountered its like before, yet he couldnt recall where…

Nonetheless, while Josh was continuing his subconscious preparations, his tension was transmitted to those close to him, and others were also not unaware of the growing danger…

To Be Continued…

but before that here is my halloween costume



Yes I was facebook. Drunken facebook. I was super poking people all night long, as well as having my wall written on, and occasionally hacked


Found you waldo. More photos when i damn well feel like it. But now on with

CONTINGENCY PLAN

Two-POST CALL

Alarms and buzzers were going off everywhere. Josh flailed about,
seeking his pager, before realizing it was his cell phone. He shut off the alarm and glanced at the time. 5:00am November 1st. Time to begin pre-rounding on patients. It had been a long night of call, not entirely unexpected given the holiday. Multiple people had come through the ER, but he only had to deal with the traumas, most of which went to county, bless their overworked little hearts. Therefore, no shootings, and almost no motor vehichle accidents, just a couple drunken lesbians who hit a parked car, one wheelchair bound gentleman with some kind of animal bite, and of course the intoxicated zombie.

So down to the floors he went, waking up each patient, and going over the standard 5 questions that are pretty much all any surgeon cares about.

“Good morning mr/mrs [whatever]. Any problems during the night? Did you eat? Did you pass gas? Did you have any bowel movement? Have you been able to walk at all?”

Almost every patient usually responded positively to the questions unless they were fresh out of the OR or had something really serious. Surgical notes weren’t particularly hard to write, especially after medicine. Last stop was 3rd floor, Mr Greenberg, the intoxicated undead.

“Heh. With all those stitches in his chest and neck, he looks a lot more like a zombie now-too bad halloween is over buddy.” Josh didn’t waste time asking the surgical note survey, partly because he was tired on only 2 hours of sleep, mostly because Mr Greenberg was still intubated in an induced coma and unlikely to answer anyway. However Josh still went through the focused exam, hearing a regular, if slow rate and rhythm of the heart, clear breath sounds, and intact deep tendon reflexes. According to the computer monitor, the vital signs were stable, but the oxygen saturation and tempurature were a little bit lower than they should be at 92 and 97.1, respectively. “Hmm…he should be satting higher than that, but it’s still within normal range. guess i will let the nurse know”

Bright told Josh not to worry about it as he had been consistently satting low, probably due to his asthma, and the temp was most likely due to a low fever, since his white count clocked in at 11. Josh finished all his notes and went off to meet with his resident for rounds.

…

Rounds passed by without too much pimping, mostly just a few questions on MRSA management, probably because everyone in the hospital was talking about the new outbreak of whatever the new super bug was that was resistant to drug treatment, and how much work it was going to end up creating for the entire hospital and ancillary staff. Josh went to chat with his intern about the plan for the day’s patients, aka “running the list”

“Hey Raj-so what do you want me to take care of today?”
“Hey Josh-not too much, just call radiology for the reads on those x-rays for the lesbians, talk to ID {infectious disease} regarding the bite on our guy in 72, and oh, what’s the status on Greenberg?”
“Meh…white count’s 11, but we’re pumping him full of avalox and cefotaxime, should clear up. He’s satting kinda low for someone who’s tubed, but bright said she would keep an eye on it and call you if anything changes”
“Screw that-she can call hector, today you and I are post call, and that means we are out by noon”
“Fine by me, just letting you know”
“Alright then let’s take care of this shit and call it a day.”

…………….

The next couple of days went by as usual. The lesbians got discharged, wheelchair bite was transferred to medicine’s care under ID’s recommendation, new patients came and went. Actually, more patients were coming than going, at least for those stuck on medicine. Apparently the new superbug had finally worked its way over to the northside, and several patients were on the floors in isolation rooms while the hospitalists tried to figure out what the heck to do with them. Also somewhat disturbing was that Mr Greenberg’s white count had continued to climb, reaching 15, well outside the normal range of 4-10; yet rather than being febrile, he was actually dropping in temp, far closer to hypothermia than anything else. Josh continued to exam his wounds for any signs of infection, but aside from the high white count, and low temp, everything appeared stable. It looked like Senor Greenberg was setting himself up for a long stay in the SICU.

………….

Two weeks later, Josh was relaxing at Mickey’s, throwing back a few beers with friends and fellow med students Phil and Tammy. They were doing what they usually did, what all med students do when they gather: bitch about med school because they simply have no idea of other conversational topics anymore.

“So Phil, any horror stories from peds?”
“Where to start-I swear pediatrics might as well be vetrinary medicine. You are treating a bunch of animals who cant tell you what’s wrong, when it started, and the only way to treat them is to put up with their handlers…erm i mean parents, most of who are too obnoxious to teach their kids how to behave.”

“Heh, well at least they don’t lick your face, man. What about you Tammy?”
“Nah, ER is same ol’, same ol’. Lot more people with that new MRSA coming in and getting transferred to medicine”
“Yeah we have a bunch of those people too…what have your docs been doing with em?”
“Truthfully, nothing much…they come in sick, we give them drugs, it doesnt help and they either sit on the floor while ID shits their pants, or they spike a fever and die, clearing a bed for the next one in with the same problem”

“You have had them die?”
“Well, yeah, but mostly its the elderly and kids who are coming to us, and its not like they’re in great health to begin with.”
“So what are you doing with them?”
“I just told you.”
“No, I meant the dead ones”
“Oh, we kept one or two for autopsy, but the rest are either returned to their families for burial or burned”

“You guys want to hear a freaky story?”
“Yeah Phil what’s up?”
“We had one of those kids. Caught the bug, spiked a fever…except you know how it is with young kids, you spike a fever to high you can go into febrile seizures. Well the parents swore up and down the kid died right in front of them, shuffled of this mortal coil, ya know? But while they were mourning in the other room, he up and crawled in walking a little funny but otherwise good as new. I reassured them that he seized, not died, but we admitted him to the MICU anyway…mostly to monitor, since no one else has managed to cure themelves of the new MRSA. I mean the fever is clearly broken, his temp is like 94, low if anything, but you know these hispanic parents and how every little thing gets blown out of proportion.

“Alright guys, well I gotta go, things to study, lives to save, you know how it is…same time next week?”
“Yeah, see ya later Josh”
“Later man”

…but it was only the beginning…

TO BE CONTINUED

Well folks, its November is National Novel Writing Month, or NaNoWriMo for short. This year I have decided I will try and participate, and while I am not promising an entry every day, I will attempt to give you all at least a complete short story. So if at any point you would like to read this in its entirety, it will be tagged as NaNoWriMo

Here are the only rules I am setting for myself-
1)No matter how long it takes me, I have to bring this story to a conclusion I am satisfied with
2)All characters must have logical reasons for their actions
3)Frequent commenters earn at least a cameo in the story

So here I go

CONTINGENCY PLAN

One-ON CALL

Alarms and Buzzers were going off everywhere. Josh flailed about, seeking the source of the noise, finally realizing it was his pager going off again. 2am, October 31st. All Hallows Eve.

“Great. Just great-another code yellow. How the heck did I get call on halloween” He muttered shrugging his lab coat on and heading toward the emergency room. ” Ghosties and Ghoulies and Four legged beasties and Drunks that go bump in the night.” Then he chuckled. Everything’s funny when you are sleep deprived. On his way he passed the nurses station, where Bright was watching something on the news about the latest deadly infection to run in terror from, according to FOX.

“Hmmph.” The real miracle will be if i DONT have tuberculosis or MRSA by the end of this year”

Down in the trauma bay, he gowned, gloved, and shielded, then waited for the paramedics to arrive. 5 minutes later, in came the pt, secured to the backboard, c-collar on, dressed in zombie makeup with blood dripping from his mouth and down his neck. The paramedic started giving the history to the attending while the rest of the trauma team began the primary and secondary survey.

“26 year old male with a history of asthma was intoxicated at a halloween party where he was involved in an altercation with another partygoer. He bit the person, and was stabbed with a broken beer bottle in the chest and neck. On scene, airway was intact, breathing was rapid and shallow, pulses were strong and equal bilaterally. Glasgow Coma Scale was 13. He has no known allergies and is not on any medications.”

The paramedic continued to talk, while the trauma team finished the primary and secondary survey. Once exposed, the patient had two small clusters of wounds in the left anterior chest with some small glass shards visible and one vertical incision approximately one centimeter in length on his right lateral neck. The blood from the mouth was apparently from a small cut in the gums, most likely sustained from biting the other person.

“Sir! What is your name? Tell me your name”
“Where do you live?”
“Have you been drinking tonight?”
“What is your name?”

Nothings but moans and the rank smell of alcohol came off the patient.

Suddenly he became wild, began flailing about, snapping at techs, and repeatedly trying to get off the bed.

“Dammit, he tore out his line”
“Someone help me hold him still for x-ray”
“He’s too combative right now, we need to intubate him!”
“Get the med students help, we are having enough trouble with him”

“Josh! get me Some Etomidate and Suxx.”
Sedated and semi-paralyzed, the tube was placed down the patients throat to his trachea, checking for proper placement by observing the CO2 monitor.

While all this was going on,still other members were performing the focused abdominal sonography for trauma (or FAST scan) to assess for organ injuries or intraperitoneal bleeding, and still others were suturing up the wounds in his neck

“Alright everyone, send him down to CT to check for any glass shards and proper tube placement and then up to OR. We need to close those wounds and stabilize him. And everyone- let’s keep a close watch on this one”

…in retrospect, those words would ring deadly true…

TO BE CONTINUED

Happy Halloween from karaoke zombies and teh Josh

SO yesterday was my first day of Emergency Medicine, henceforth ED or ER for those of you inundated by pop culture. The morning started off with an orientation at the not-quite-inner city hospital i will be spending the next month at, where the concluding part of orientating was a suture clinic on pigs feet.

Now let me tell you, at the end of that clinic i was thoroughly convinced that If my pig had been alive, he would have been screaming and trying to run away, and failing from the gaping wound in his foot caused by my open sutures.

And yet a mere 12 hours later, I was suturing on a real person who would do neither. But let’s back up a tad, shall we?

ED is on a shift schedule, meaning you work 8 hour shifts which are pretty much assigned at random. My first shift was the 10pm to 6am, of which I have another tonite, causing me to switch to a vampire like sleeping schedule. SO lets break it down by hour, shall we?

10pm: Arrive work. Think this doesnt look at all like the TV show. Introduce myself to the attending for the night and a few of the staff, get sent to see first patient, a chronic schizophreniz with a colostomy bag. Do you know what a colostomy bag is? It is a bag placed outside your body to act as your colon…basically a balloon of poo on the outside. Gross? Funny? You decide…i couldnt, because professionalism requires me to keep a straight face. Decide the schizophrenic has nothing immediately wrong with her and she is on her way to discharge

11pm: Next patient is a little kid with croup. Pretty simple, just learning to manhandle children for the physical exam, that things go easiest when you sit them on their mothers lap, that you can look into their mouth from above instead of below, and making goofy noises during your entire exam will be much more comforting to the child then the mother.

12am: Down time since there are 2 other students working on the trauma side of the ER who I have to share patients with. Write some notes, look over and notice a bottle of irish rose whisky and colt 45 on ice. Wonder aloud what they are doing there…informed that they were confiscated from a patient and are being kept cold. Next wonder for whom…

1am: Look up at list of incoming patients…one chief complaint is the patient “drank pine sol” Why? Because it smelled so lemony fresh he thought it would go down that way just as easy? Maybe he had a problem with streaking and mistook it for the windex? WHo knows, not I

2am: Patient comes in with huge laceration on his arm from several glass cuts. After a soccer match, he went to his sisters and knocked on the window “a little too hard” Too hard being a 6 inch long laceration down his forearm exposing the muscle, though not down to the bone. First things first, we do a bbi on him…meaning place ultrasound gel on his wrist, and the PA (physicians assistant) moves the speaker around til we hear his pulse, and then I inflate the blood pressure cuff to listen to the numbers at which it dissapears and reappears. This is done for each arm, and the numbers are compared to see if the ratio is an acceptable limit…it isnt so trauma from surgery is called down to evaluate

3am: Following the surgical eval, it is time to suture the lacerations up…and guess which med student gets to do it? YEP. The one who at 10am this morning was having trouble suturing a pigs foot. Not that the patient was going to be informed of this. Thats what you get for going to a teaching hospital folks. So first things first, we irrigate the wound with sterile saline to wash out a bunch of blood and debris. This is followed by a lidocaine injection performed by yours truly…around each of the corners of the wound, a constant stream to make sure the entire area is numbed enough for a med student to suture. Thank goodness, because if i had to do it without him anesthetized it might have turned out like the pigs foot

3:15am: look at gaping wound in pts hand, idly wonder about zombie bite. SHake head, realize I am tired.

3:30 finally its time to start throwing sutures. First things first…the resident sutures closed the muscle tear, because that is a little too important to leave to a med student whose first patient it is suturing. Then the fascia layer is closed by both myself and the PA, with a tie known as a vertical mattress tie to place less tension on the wound. Takes longer to do, especially since neither of us knew this tie before tonite, but he is numbed up enough to not notice. Then the resident leaves us to close up the most superficial layer of skin because he can see we are capable of handling it.

4am: So the first couple of instrument tie sutures i throw to close the skin are not pretty…but the patient was told that given the size of the cut, he is going to have a scar anyway, and its on his forearm not his face, and he has no clue of my relative inexperience and i am certainly not going to tell him

JOSH’S RULE #176: ACT LIKE YOU BELONG, AND PEOPLE WILL ASSUME YOU DO

The initial laceration required about 9 stitches to close and by the end i was doing just fine with tying, and spacing, though still leaving a little too much cord at the tail end to get cut off…oh well that will come with experience. And there was no screaming by the patient, no doubtful questioning by the family member present, no sniggering by the PA, and no wtf by the attending and resident who came back in to check the sutures…just a good job, next time try and place them a little further from the wound.

5am: Place the last few stitches in the gentleman, a total of 9 in the largest cut, with another 6 underneath those, then 4 in the next largest cut, and 2 in some minor cuts. I am a suturing machine with a sore back.

5:30am…avoiding all patients, finishing up paperwork

6am: leave the hospital after first overnight call

7am:arrive home, fall asleep

1:10am: wake up, have breakfast, go to xanga so you could all share my story.

And remember, if anything goes wrong during the next month…

-J

And that’s why we hide the eggs: So Zombie Jesus can’t find them.

ADVENTURES IN AIM
coffeeweasel: Apparently then small children are smarter than Zombie Jesus.

Ieatyoursoulz:Makes sense. Jesus said that to enter heaven, you must be like a child.

coffeeweasel: That’s probably your trial when you go to heaven: Find the eggs.

Ieatyoursoulz: Yeah.
None of this ‘sitting in judgement’ crap. It’s just Peter at a podium
taking your name, and asking you ‘Did you find the egg yet?’

coffeeweasel: You
know, we never learned Peter’s last name. I’ll bet it’s Cottontail!
THAT’S IT! SAINT PETER IS THE EASTER BUNNY! So it’s HIM hiding the
eggs. That rascal.” (as per south park revelations)

Ieatyoursoulz: That’s why we hide the eggs down here. Much
harder for Zombie Jesus to find them when they’re not up in heaven.
Hell, why do you think he came in the first place? Not to save
everyone. He just wanted to find a couple eggs because he’d been
itching for an omlette since creation. that’s why we
color them: to confuse Zombie Jesus if he DOES find one. ‘What? What’s
this blue thing?? It can’t be an egg. It must be a rock.’ And let’s not
even get into the multi-colored ones.”

-J

A while ago, i had written a post about some bakery in thailand called the human bakery, or the eat bakery, or something to that effect. I have an ongoing fascination with cannibalism and zombies, as those of you who know me well may recall, and when i decided to actually go to thailand, I did everything i could to try and track down this human bakery in hopes of eating a human. But i am getting ahead of myself a bit. Lets go back to the beginning…

Attn: This place is seriously in the middle of nowhere, even a bunch of thai people i asked had never heard of it, INCLUDING our tour guide. So if you are ever inclined to go looking for it yourself, shoot me a line, and i will give you what info i remember

hmm…looks normal enough, you say, just a household making cakes for chinese new year…but then, through an open door, you espy

ZOMG!!!

once we got our foot in the door, we wondered, what kind of sick person could be fascinated by such things?

well, other than me mmmm BRAINS!

earlier attempts. btw, all these things you are seeing are made out of bread. yes, bread. and then coated with some kind of preservative so they can remain all delicious looking forever

Ward wasnt too picky about trying things, and Koh just wanted to pig out

but i can always use a hand in my adventures

soon we had to face the music, it was time to head out

we didnt lose our heads though, and made sure to credit the artist responsible for such work

Take a good look folks. This might just be one of the happiest moments in my life

at least until crystal succeeds in finding where this restaurant in japan is for me…

mmm…japanese banquet of cannabalism

Next time, return to bangkok!

-J

As noted on Justgotpaid’s site:

TOKYO
(AFP) – Japan’s health minister has come under fire after referring to
women as “child-bearing machines” in a speech on the country’s
declining birth rate.

“The number of women aged between 15 (since when was 15 a good age to have a child??)
and 50 is fixed,” Hakuo Yanagisawa said Saturday at a meeting with
local members of the ruling conservative Liberal Democratic Party (LDP)
in the western city of Matsue, Kyodo News reported.

“Because the number of child-bearing machines and devices is fixed, all we can ask is they do their best per capit

-baby making machines, eh? well machines are needed for mass production, especially when the product is so darn tasty!

 Yes, there has been quite the recurrence lately of Jonathan Swift’s a modest proposal. So here are some examples of the new sensation that’s sweeping the nation, baby eating for fun and profit. This post is dedicated to my brother, a lover of children and all things delicious

By the way, that last pic is from an actual store in naperville illinois. I knew chicagoans liked their meat, i guess i just underestimated how much
-J

Via: VideoSift