Weekly Whine: Updates

Why is everything on my computer and phone constantly needing to update?

Every time I open practically any application, it harasses me to install updates (I'm looking at you, iTunes). You know what I want to do when I open an application? I want to USE it. I don't want to wait five minutes to install updates.

The worst is when I'm at work and I try to open, say, epocrates to look up a drug, and it won't let me use it till I install the updates. So I have to sit there, waiting for the updates to install on the slow as ass connection, before I can figure out the correct dose for freaking Detrol.

Lies I told as a med student

Bikers

It's my pet peeve when I see people riding bikes without helmets. Especially kids. Seeing enough brain injuries will do that to you.

There are these two girls (age 8 or 9) who are always riding their bikes in the parking lot of our housing complex. At one point, one of them zipped out of nowhere and I almost hit her. Granted, I wasn't going very fast, but she's a little kid with a little skull. It freaked me out.

I rolled down my window and firmly told the girls that they absolutely need to be wearing helmets. That it's really dangerous. They said they understood and went back inside.

Well, guess what? Yesterday I saw them riding around again with no helmets.

I don't know what to do. Obviously, yelling at them is pointless. Do I seek out their mom and tell her? I get the feeling I'm just going to be told that it's none of my business. I'm really not a busybody and I think it's obnoxious to tell people their child is doing something wrong. But this is a safety issue!

Things I hated as a kid and now love

1. Avocados

2. Catcher in the Rye

3. Shopping

4. Eggplant

5. Books written by British people

6. Lox

7. Tomato soup

8. Summer

Dr. Orthochick: I'm standing right here!

ER Patient: Is Dr. PGY3 on tonight?

Me: No, sorry.

ER Patient's husband: Really? That's too bad. She's our favorite.

Me: Yeah, she's really nice. And very smart.

ER Patient: [to husband] I don't like this resident as much as Dr. PGY3

ER Patient's Husband: [to patient] She seems OK, I guess.

ER Patient: [to husband] Well I think she's OK but she's nothing like Dr. PGY3.

ER Patient's Husband: [to patient] That's true. But maybe we'll wind up liking this one.

At that point, the resident in question decided to just leave the room already. Seriously people, can you wait until I'm gone to talk about me?

Maternity Leave by Country

This image was in the NYT:



Apparently, the US is one of only EIGHT countries in the world that does not give a paid maternity leave. What a disgrace.

I've argued with a lot of people on this blog (most recently on this post) who feel that having kids is a choice and ask why our country should do anything to support women who make this "choice". But I think a better question is:

Why is our country the only one who DOESN'T support women who have kids?

Well, except Liberia.

Weekly Whine: Ear buds

Am I the only one who feels like ear buds really hurt your ears? (Stethoscopes also hurt my ears)

I usually use the ones that hook around my earlobes, but I can't find one like that that I can use as a hands-free device for my iPhone. So I'm stuck having my ears in pain.

Daycare is expensive yo

For anyone who expressed shock when I said that my daycare costs were $40K for 2012, this article shows that I actually got off cheap.

2013 isn't going to be much better for me. The tuition for my youngest just went up to $420 per week. Per week! But 2014 will be much better since the public schools are decent so we don't have to splurge on private school.

Should the government subsidize affordable daycare for working families? I say hell yeah.

Gloves

Resident: "What size gloves do you need? I got out larges for myself."

Me: "I don't need gloves. I'm actually going to touch the patients with... my bare hands!"

Resident: "Oh."

Me: "Unless I have to do a rectal exam." [pause] "I really hope I don't need gloves today."

Seriously though, I never wear gloves when I examine patients. Unless of course, I'm sick... or the patient is icky. For most patients, my bare hands are fine, but for others, mere gloves aren't enough and I'd ideally like to be wrapped up in some sort of germ-proof bubble.

Things that I loved as a kid and still love

1. Zach Morris

2. Archie comics

3. Ghostbusters

4. The Muppets

5. Math

6. Ramen noodles

7. McDonald's

8. Reading

9. Drawing

10. The Wizard of Oz

Dr. Orthochick: Doppelganger

I had a Little Chick*** with me for a dressing change this morning because they're all required to watch a certain number of dressing changes, G-d only knows why. So whenever I do one, I page all four of them and ask if anyone needs to see one done. Usually they ignore me, which is fine because I can handle these things on my own and I don't need assistance or an audience.

Today one of the Little Chicks (I would give them names but since they're all kind of the same, it's not really worth it) came with me, I guess he was exceptionally bored or had half an hour to kill. It was this giant sacral decubitus ulcer so I actually did need some help with it, so it was nice for me to have a med student instead of having to ask the nurse to hold the patient for me. To reward Little Chick for actually paging me back, I let him do the whole thing. (This is really not all that exciting. I showed him how to do a wet-to-dry dressing and he went to town. He was actually pretty terrible, but the patient was getting a wound vac placed later that day anyway so I decided that it wasn't worth it for me to interfere and he should just learn on his own that tape works better when you don't scrunch it up.) Then since I had just read an article on decubitus ulcers in JAAOS, I tried to teach him some stuff about them. The patient screeched the whole time, but I'm not convinced that it was due to pain and not just her being a tad floridly psychotic.

It was cute, Little Chick responded pretty much exactly the same way as Orthochick.

Me: Thanks for helping me out with that

Little Chick: Thanks for letting me help!

I really am trying to be a good resident. I don't really operate much so I can't bring the Little Chicks into the OR with me, but if I'm doing something on the floor that either I think they'll find interesting or they need to do, I will bring them. And if I'm doing a consult for something other than feet, I'll usually page them to see if they want to see the patient first. And every now and then I attempt to teach something if it's relevant. If I'm doing something, I always try to let them do it too instead of just watching me. If I see they've written a note on a patient, I'll always thank them for doing it.

Me: I saw your note in the chart this morning for Ms. Smith.

Little Chick: Was it OK?

Me: Ummm...didn't she have a laparoscopic cholecystectomy?

Little Chick: Isn't that what I wrote?

Me: No, you wrote she had a laparoscopic appendectomy for acute appendicitis. She had a laparoscopic cholecystectomy yesterday for gallstone pancreatitis.

Honestly, I know I'm not very bright and I don't really know anything about general surgery, but I'm pretty sure the Little Chicks are no more on the ball than I am most of the time. Maybe that's why they remind me of me. Or maybe it's because I get the feeling that even though they screw up a little, they really are trying. And I can relate to that. So I really do like them and I appreciate what they do. And honestly, I like their enthusiasm. I like the way they find it sorta kinda fun to do a dressing change on their own.


***MS3 med student

Ancient device

My husband was reading my toddler a Berenstein Bears book the other day. I heard the following exchange:

Toddler: "Doggy!"

Husband: "Right, that's a doggy."

Toddler: "Mama."

Husband: "Right, that's the mama."

Toddler: "Door."

Husband: "Right, that's the door."

Toddler: "What that?"

She was pointing to something that looked like this:



Husband: "That's a phone. That's what they used to look like."

Gunners vs. Nerds

Gunners are the most competitive and backstabbing of all med students. However, some of your hyper-competitive classmates may not really be gunners--they might just be huge nerds. Take this quiz to figure out which one you are.....

Are you a gunner or a nerd?

Guest Weekly Whine: Pagers

Why is it that whenever I mention my pager, everyone acts like I have jumped in a time machine? I get that they are obsolete for most people, but they are UBUIQUITOUS in medicine, and for good reason. Cell phones don’t always have reception, you can keep your private cell number private, but, most importantly, when you get paged at say, 2am, you don’t have to be immediately awake and alert. I treasure that 1 – 2 minutes to collect myself and get into a mental space where I can respond to questions coherently.

And it’s not like people don’t know that healthcare providers use pagers, is it? Whenever anyone sees my pager, they say “you’re a doctor, aren’t you?”

Snarky jokes about pagers don’t apply to healthcare providers. That’s what I’m saying. We use them, we need them, and they serve a real purpose. Therefore, jokes like “whoa, a pager! What is it, 1991?!” are not funny.

--Contributed by Dr. Alice

Mnemonics, Part 2

Guess which mnemonic each drawing represents:

Color

In our Emergency Department, different sections of the ED are designated by different colors and each color is covered by one nurse. So there's a nurse for Orange, Red, Purple, etc.

An ED attending I was chatting with recently was telling me that there used to also be a section for Black. He said that lasted exactly one day, until the first time they called over the intercom, "Will the Black nurse please come to the nurse's station?"

Apparently, that made everyone very uncomfortable.

Dr. Orthochick: Sexy Time

My patient yesterday was really starting to make me uncomfortable. And we spent a significant amount of quality time together because I had to do a dressing change on him and pretty much the exact second I finished it, the attending walked in and undid everything to look at the wound and then told me to re-dress it. (He also neglected to say "please" or "thank you.")

Patient: You are such a cutie.

Me: Uh, thanks

Patient: No, I mean it. I always wanted to marry a beautiful young girl like you.

Me: Bend your elbow a little more.

Patient: So I'm getting discharged today, right?

Me: Yup

Patient: I don't think I have a ride home

Me: I'll talk to social work about it.

patient: Why don't you just give me a ride home?

Me: Because I have to stay at work for a while longer

Patient: I'll wait for you. And if it's easier, we can go back to your place and I can just stay there for a while.

Me: I don't think that's going to work out too well.

Patient: Why not? I can keep you up all night if you want.

Me: Straighten out your fingers.

Patient: So why can't I go home with you? I'm really trying to court you, in case you haven't noticed.

Me: OK, one more layer of ace wrap and then we're done

Patient: I just want to live with you. We don't have to have sex right away if you don't want. But I bet you haven't had really good sex for a while.

Me: OK, don't get the bandage wet. See you later.

Patient: So we're not going to have sex at your place? Do you want to have sex here?

Me: Have a good afternoon.

I was telling a male resident friend about this and he said he was jealous because his patients never seemed to want to have sex with him. I told him if he wanted my married hepatitis-C positive unemployed heroin addict without teeth and status-post flesh-eating bacteria infection, he was more than welcome to him.

As for me, I really think I can do a little bit better.

3 words

Whenever I give a patient three words to remember as part of the mini-mental, I always use the same words:

Apple, table, penny

Because if I switch them up, there's a very good chance I will forget which words I used.

I've heard reasons why people use certain three words, but frankly, I like my three words.

What are yours?

Old but still good

If you haven't already, take my quiz....

Should you go to med school?

Weekly Whine: The Mindy Project

For the record, I really like The Mindy Project. That's the new show featuring Mindy Kaling (Kelly from The Office), in which she plays an OB/GYN. It's really, really funny. Like, from the very first episode. I highly recommend it.

That said, I wish she weren't an OB/GYN. Because it's freaking driving me crazy:

1) The male/female roles are way off. In the practice, it's 3 men plus Mindy. That is so rare for an ob/gyn practice these days.... but most doctors on TV have to be men, I guess. And the competing midwives upstairs? They're men too! WTF??? How are midwives men???? I could deal with it if it were meant to be a joke, but I don't think it is.

2) They don't seem at all invested in the practice. Mindy and her coworkers will just up and leave for a field trip to a high school without any notice. That is NOT how any medical practice on the face of the Earth actually runs.

3) They don't actually see patients. No, not one patient in the half-season I've watched so far. Well, maybe one.

I like the show and it's really funny, but what was the point of making her an ob/gyn if they're not going to have her do anything even remotely related to being a doctor? Why didn't they just have her work in, like, an office or something?

Weird Allergy

In the last two years or so, I've noticed that whenever I eat certain fruits, my throat becomes really itchy. It mostly happens with peaches. Right after eating the fruit, my throat gets itchy and sometimes almost feels like it's closing up a bit, which is a little scary. It usually goes away in about five minutes. Needless to say, I've avoided peaches.

Yesterday I took a bite of an apple though and I got that same itchy, uncomfortable feeling in my throat. I IMed my mother about this and said that I thought I had some sort of allergy to certain fruits.

Mom: I think you are imagining things.

Me: Dunno, I've been getting this for like two years

Mom: It sounds neurologic.

Me: You mean it sounds psychological?

Mom: Yes.

Me: You always say that. Like when I was allergic to the mold in your bathroom and you kept telling me it was psychological, then you cleaned the bathroom and I was fine.

Mom: But you grew up here. And all of a sudden you couldn't stay in the living room.

Me: Because you had MOLD!

Mom: It is not that long after though.

Me: Well, maybe I got accustomed to the mold when I was living there, then I lost my resistance. Or maybe the mold got worse.

Mom: Maybe a combination.

(You could literally SEE mold growing on the walls of the bathroom. My husband was horrified.)

I then looked it up on google, which informed me that I may have Oral Allergy Syndrome. Apparently, this is something where if you are allergic to pollen, you can also be allergic to the proteins in certain fruits that resemble pollen. From the description, it sounds like just what I have. Especially since I don't get this symptom from applesauce, which is processed.

It sounds like apples, peaches, cherries, and pears are some of the most common, which is consistent with my symptoms.

Bowl

Social Worker: "Mr. Jones smokes a lot of pot. He said he smokes..." [checks her notes] "A bowl of pot each night. I don't know how much that is, but it sounds like a LOT!"

Neuropsychologist: "It's not like a cereal bowl."

No Kids

This is an article I posted on Facebook that generated a lot of discussion so I'm posting it here:

I'm Coming Out: I don't want children

The article talks about how she now feels a kinship to the LGBT community due to her decision not to have kids.

This article irritated me on a few levels:

1) Comparing the plight of gay people to a couple who doesn't want to have kids is pretty insulting to the LGBT community and what they go through. Even just calling it a "choice" shows how different it is. I make tons of choices that have been subject to criticism (e.g. choosing to work as a mom) but that doesn't mean I know what it's like to be persecuted for my sexual preferences.

2) You're 27??? Write this article in another 15 years. Because I think every single one of my friends in their 20s who strongly didn't want kids have somehow changed their minds.

Dr. Orthochick: Poo

I got stuck in general surgery clinic today AKA "please tell me more about your episodes of diarrhea" clinic. Seriously, general surgery is obsessed with bowel movements. I forgot that little tidbit and I didn't ask my patients if they were passing gas appropriately this morning. In clinic, all I did was talk about poo. I figured it was a new low in my clinical life when I had to ask patients to please describe the quality of their poo--the texture, color, odor, etc.

It got worse--In the middle of clinic my second patient decided that she needed to poo. Not only did she need to poo, but she needed me to take her to the bathroom to poo. Then once she was done, she showed me her poo. Then she needed someone to bring her back to her room, status-post poo, so we could talk a little more about her poo.

It was a new low, even for me.

I appreciate a good fart joke as much as the next chick, but this is actually pretty gross. I don't like looking at my own crap in the toilet--I really, really, really do not like looking at other peoples'. I'm really glad that I don't have to deal with the colon in my real life. If the postop ortho patient is constipated, you chalk it up to their pain meds and give them a laxative. If they're having diarrhea, you chalk it up to their antibiotics and increase their fluids. I guess this month I'm supposed to be learning more about poo so that I have options besides those two, but truth be told, I really don't want to learn more about poo. I have no intellectual curiosity as far as dung is concerned. And I'm OK with that at this point in my life.

Personal Statement

I was recently reading a personal statement for a med student. In all honesty, it wasn't great. It had some grammar issues, and it was sort of all over the place.

That said, I don't think the personal statement matters at all. So I was hesitant to tell her to rewrite it.

Am I wrong? Does the personal statement matter more than I think?

(Maybe I should have recommended the template....)

Female preference

I recently got my very first massage.

It was nice. I think. I didn't like the part where she was literally punching me for several minutes but other than that, it was relaxing. I have to admit, one thing I thought to myself was that I don't think I would have enjoyed it as much if a male were giving me that massage. I think I would have felt uncomfortable.

I feel the same way when I go to the doctor. I've had some great male ob/gyns, but everything else being equal, I'd definitely choose the female. (Everything else is not always equal though... I would have taken any male doc in the practice over the woman who delivered my youngest.) I know a lot of women feel the same way.

Actually, in probably any situation where there a lot of touching involved (massage, physical therapy, physical exam), I'd prefer a female over a male. And I find it pretty hard to believe that most women don't feel the same way.

Medical Specialty

What medical specialty is for you? If you haven't taken my fun quiz before, take it now! Or else, take it again with a fancy new look:

What medical specialty is for you?

Weekly Whine: Tips for service

When you go to a restaurant, you tip your server. The waiters depend on tips to make a reasonable salary. Yet when I go out to eat, these are the things that generally impact my dining experience:

--Quality of the food

--How fast food comes out

--How busy the restaurant is

--Attentive waiter

I'd say at least 75% of it is all about the food. Yet it's the waiter who gets the tip. And if the food sucks or is great, there really isn't anything you can do about it. For example, we were recently at a restaurant and got just about the worst food ever (clearly reheated hamburger patty), but we didn't want to wait for a new burger that may or may not have spit in it. And what could we do about it? Nothing. And we still tipped well because it wasn't the waiter's fault the food was awful.

Cross Cover Help

This is a guide I made for myself before starting cross cover as an intern. I figured it might be helpful for those of you just starting internship:

Altered Mental Status

First ask: “Is this actually altered? Or are they always completely insane?” Often it’s the latter. Then you better go examine them or something.

Get the usual labs first. This person has probably had ten zillion fingersticks, chem panels and CBCs, so one more set can’t hurt. Also, an EKG. Why not?

Get oxygen saturation and maybe an ABG. Newsflash: not being able to breathe can affect your mental status.

Infections can also make you act weird, especially if you’re old. Is the patient running a fever of 106? That might also be a clue. Check the urine, check the blood. Get a CXR. If you’re really desperate, check the spinal fluid, although this will likely be low yield since most interns are unable to do a successful tap on their own.

Another thing that can cause a patient to be altered is giving them 20 mg of ativan. Did you OD your patient on ativan today? Think hard. Other meds can do it too. Especially the ones that can cause a urine tox to be positive.
Maybe a head CT too… what else are you going to do with $2,000?


Chest Pain

Get cardiology consult… haha, just kidding.

Ask a buttload of questions about the patient’s history, but likely get the same tests regardless.

Get the chem panel, the CBC, the cardiac enzymes, the EKG. If you suspect a PE and you want to order something really useless and annoying, get a d-dimer.

If it hasn’t already been done, do the usual fun stuff, like giving aspirin, oxygen, morphine, and nitro.

If there are changes on EKG: panic.

If everything else is negative: GI cocktail


Hypotension

Uh oh.

The differential for this is wide. Could be an infection with sepsis (yah!), could be just dehydration, could be a bleed, could be some cardiac shock, could be medication related.

Is the person peeing? Peeing is always a good sign.

First give some fluid, cuz why not. Shove in those two large bore IVs.

Does the patient look sick? Have a fever? Vomiting up huge amounts of bright red blood? Having massive diarrhea? Chest pain radiating to the left shoulder? Look for clues that will spare you the annoyance of having to think on your own.


Decreased Urine Output

First, has the patient peed less than you have in the last six hours? If yes, then you’re in trouble (both of you).

This is kind of similar to the hypotension thing in that a lack of fluid in the body can cause it. Or it can be that there’s enough fluid, but it’s not getting turned into pee. Or it can be that it’s getting turned into pee, but the pee isn’t coming out.

Is the foley plugged? Flush that sucker!

Treating this usually involves some combination of checking the BUN/Cr, and a balance between giving fluids and giving lasix.


Hypokalemia

Huh? Why’s this on the list? Just give potassium, what’s the big deal?


Hyperkalemia

This is a little scary, depending how high the K is. Get an EKG and if there’s anything that looks like peaked T waves or something like that, better give some calcium.

If the patient can poop, give some kayexelate. Or you can go the insulin/glucose route.

Maybe dialyze if really bad.

And for god’s sake, stop adding K to the IV fluids.


Hyperglycemia

This is my favorite thing to go wrong.

Me: “Give patient insulin.” (now I’m the hero)

I guess it occasionally requires a little bit of analysis, if the patient looks DKA-y. So maybe consider a chem, acetone, UA check. If there’s an anion gap and ketones, you probably need to transfer the patient to the ICU so that someone more experienced than you can take over.


Hypoglycemia

Drink some juice.

Or take an amp of D50, whichever.


GI Bleed

Ugh, I hate GI bleeds.

First off, it depends how much they’re bleeding. A drop of blood on the toilet paper is not a GI bleed. Blood gushing out of the mouth probably qualifies.

Remember the ABCs. Make sure the patient is stable, stick in those two large bore IVs. Give fluids. Type and cross. All the fun bloodwork, especially a CBC, coags.

At this point, the source decides the treatment. But either way, you should probably stop the heparin drip.


SOB

No, this doesn’t mean the patient is being an asshole…

A lot of people are SOB at baseline. Is this new SOB. Or is he an old SOB?

I could write a page-long list of things that cause SOB, so it’s important to narrow it down with history and physical. You’re probably going to want to get labs, a CXR, an EKG. Definitely a pulse ox, maybe an ABG.


Hypertension

Generally it’s good to find out a little bit more about the patient’s history of high BP and if this is a new thing. Or if it’s symptomatic hypertension and there’s evidence of end-organ damage. (Uh oh)

Mostly, I just give hydralazine. I love that shit.

Good luck!!!

Mnemonics

Which drawing does each mnemonic represent?