Thursday, July 31, 2008

garp quote

just started reading for fun, from irving's the world according to garp:

"She felt if she ever had children she would love them no less when they were twenty than when they were two; they might need you more at twenty, she thought. What do you really need when you're two?

In the hospital, the babies were the easiest patients. The older they got, the more they needed; and the less anyone wanted or loved them."

Sunday, July 27, 2008

q2 and randy pausch

Post-call from medicine service, starting cardiology tomorrow and guess what? I'm on call! I'm going to sit and vegetate at home today.

In other news, Randy Pausch passed away on Friday, 7/25. Sad sad news. :(

Friday, July 25, 2008

Med Culture: Phrases I Hate

Phrases That Annoy Me (used by med folks among themselves):
- "touch base" with med onc/neuro/etc.
- "teaching point"
- "common things being common"

Phrases I Like:
- "our service"
- "patient census"

"only at Moffitt"

Since my first two blocks have been at Moffitt -- UCSF's fancy shmancy ivory tower tertiary medical center -- I'm starting to realize that my view of medicine can be a bit skewed. Someone observed that yes, we can get regular bread-and-butter medical cases like pneumonia or heart disease, but there's usually some exotic past medical history (a transplant, a rare genetic disorder) or some unusual aspect of the case (patient has PCP pneumonia). We see patients that can be very sick, and an attending warned us that it is not uncommon for a fair number of patients to pass away at Moffitt.

Some people have jokingly dubbed Moffitt "the Death Star," partly because of the complexity/severity of the cases, but also because there appears to be this consensus that the medical culture at Moffitt is highly intense, demanding, and academic.

From my perspective, there appears to be some truth to the rumors, but I wouldn't have ranked Moffitt so highly on my list if I wasn't interested in seeing rare medical cases (nicknamed "zebras" in medical slang, as opposed to the more common afflictions called "horses" ). I have always had a soft spot for academic medicine, and it's interesting seeing how different specialists work together to unravel or treat challenging medical conditions. Later this year, I will be doing family medicine in the Bay area, ob-gyn in "rural" Fresno, and neuro-psych at the General (SFGH), so there will be an interesting mixture of sites and practices to experience.

However, I am enjoying my time at the medical Ivory Tower with the aforementioned zebra folks. In pediatrics, I saw a patient with a disorder so rare that it affects 1 in 2 million people and there are only 230 cases in the U.S. It was also fairly common to see kids with fetal or neonatal abdominal surgeries, 2 babies with short gut syndrome who are on Hospital Day #301, kids with rare genetic mitochondrial disorders, a 14-year-old with a stroke who left AMA, a teenage boy with lupus (SLE), and a 12-year-old boy with anorexia. Kawasaki syndrome was not an outrageous differential when a child had a fever for over 3 days.

Adult medicine at Moffitt has been similarly intense and interesting. During our last intersession, Dr. Don Ganem told us anecdotes from his days as an infectious disease fellow at UCSF in the 1980s during the HIV/AIDS era, and how bizarre infections like PCP pneumonia, cryptococcal meningitis, and Kaposi's sarcoma became "bread and butter" cases at SF General Hospital and Moffitt. When he asked a third-year med student what the most common cause of community-acquired pneumonia was, the MS3 answered, "PCP." Dr. Ganem continued by saying, "I was going to whale on the student, until I realized that that was really all that he ever actually saw in the hospital." Sometimes, I can sympathize with the situation of Dr. Ganem's hapless student -- all zebras and no horses.

Our medicine service had 11 patients, three of which were double-lung transplants. We usually have at least 1 lung transplant patient, sometimes a kidney transplant or a patient with a rare cancer (adult rhabdomyosarcoma of the cervix, primary CNS lymphoma and HIV negative, a metastatic paraganglioma presenting like pheochromocytoma). Many of our patients have serious bacterial infections, and some have end-stage liver or renal disease.

Whenever a resident or attending hears a fantastically unusual medical case -- say, a 22-year-old with a STEMI, intermittent fevers, acute renal failure, bilateral PE's, and a violaceous vesicular rash on the left side of the body -- there is a classic reaction: the doctor's eyes widen slightly, the eyes roll up to the ceiling, there is a deep sigh, and finally exhalation of the ritualistic phrase, "Only at Moffitt."

Lunchtime conversation with a fellow med student at Moffitt:
A: "My vision has been blurry and my head hurts lately...I think I have a brain tumor."
B: "Are you sure it's not a vasculitis...or a demyelinating disorder?"

Friday, July 18, 2008

Troponin Leak?!?

Doctors keep throwing around the phrase "troponin leak," and I came across this doozy paper while reading up on the mysterious term:


Cardiac Troponin I Elevation After Orogenital Sex During Pregnancy

José Mauricio Sánchez, MD1, Michael R. Milam, MD, MPH2, Tracy M. Tomlinson, MD3 and Michael A. Beardslee, MD1

From 1Washington University School of Medicine, Division of Cardiology, St. Louis, Missouri; 2Department of Gynecologic Oncology, M. D. Anderson Cancer Center, Houston, Texas; 3Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri.


BACKGROUND: Venous air embolism due to orogenital sex in pregnancy is an uncommon clinical event.

CASE: A previously healthy, 29-week pregnant woman presented to the emergency room unconscious 1 hour after engaging in orogenital sex with her partner. The cardiology service was consulted due to troponin elevation. Assessment was that the patient had likely suffered an air embolism with associated troponin leak.

CONCLUSION: Although a rare clinical event, air embolism from air insufflation of the vagina can result in troponin elevation and should be considered in the differential diagnosis in pregnant patients with a history of orogenital sex.

Obstetrics & Gynecology 2008;111:487-489 © 2008 by The American College of Obstetricians and Gynecologists

Thursday, July 17, 2008

edward hopper in vietnam

Sent to me by Kim, traveler/dreamer/medical student extraordinaire. Recalling my love of Hopper's paintings, she took this photos that looks strikingly Hopperesque with solid blocks of light, neutral color, stark shadows, and straight lines. Her poetic emails remind me that there is life and literature and adventure outside of the medical ivory tower -- I can't help feeling a bit like a pale imitation of Rapunzel or the Lady of Shalott.

a leaf falls

Medicine has been great so far, it is almost the end of my third week and we are on-call tomorrow. What impresses me is that almost everything can fall within the umbrella of internal medicine -- the heart, the lung, the brain, the GI tract, and infections of every kind.

What also impresses me is how the doctors at UCSF in the dept. of medicine are so devoted to educating the medical students and taking the extra time to teach us when they could easily ignore us or make us do scutwork (KIDDING). in fact, the culture of the medicine dept. at Moffitt has been so welcoming and comfortable. As a third year medical student, it's easy to feel like the smallest kid in the medicine family, and the residents and attendings recognize this and take the time to truly nurture us.

Medicine has also been extremely busy, and 8 weeks of inpatient care with call every 4 days (we don't usually stay overnight, but sometimes we can be home from 3-6 a.m.) can be a marathon. One thing that I've noticed and somewhat expected (now that there's time to be contemplative and write long blog entries) is that third year can feel rather isolating. There's not much time to do things beyond shower, eat dinner, and maybe clean the kitchen and I've been trying unsuccessfully to sleep at 10 pm. Although it's nice to see my classmates in the hospital and build relationships with patients and my team, I miss feeling connected to people outside of the hospital and having leisure time without all the weekends blurring away into a 4-day cycle of work-work-work-sleep. Watching my interns and residents, it seems like there will be at least several more years of sleepless, blurry weeks before I can be a craggy old attending who doesn't carry a pager and makes tennis dates with his colleagues (for reals).

Tuesday, July 15, 2008

Bad Puns

Resident: "IR can be very picky (PICCy)"

Me: "I don't have any patients (patience)!"

No pun intended (really):

Intern: "She's radioactive....and disobedient."
Day float: "I don't like disobedient radioactive patients...[looks down at paper]...who have anxiety."

Friday, July 11, 2008

Things Learned in Medicine (so far)

1) 80% of the time, when a doctor asks you how to initially treat a patient's condition, "IV fluids" is correct. This does not work for CHF. It does work for pancreatitis.

2) Our attending teaches us to -- above all -- "do what's right for the patient." I have found that this mantra can rarely lead you astray.

3) In terms of H&P presentations, accuracy > speed > thoroughness.

4) Food is good for the soul

Wednesday, July 09, 2008

Lost in Medicine Land

Sorry for the paucity of postings...I've been spending 70% of my time at the hospital learning how to think about sick grown-ups. Medicine has been great so far; the culture is definitely different from peds, but I feel more comfortable in medicine than expected. In peds, the residents almost never wore white coats and had silly colorful toys. In medicine, everyone wears a white coat and the whole setting is slightly more formal, but still comfortable and very dedicated towards nurturing the med students. :-)

This morning, I got a numeric page on the 14th floor of Moffitt, so I called back saying, "this is Stephanie returning a page."

"Stephanie? Stephanie Chang?" the voice said on the other line.


"This is the ICU attending," the voice continued, "and I have to say that I am very disappointed..."

at that point I started experiencing dyspnea...

..."your progress note this morning was horrible..." vitals were HR 99, BP 150/90, RR 22


It was a classmate of mine playing a prank on me. In the hospital.

If I wasn't the victim, I would say that it was genius....