Sunday, July 19, 2009

funniest quote of the day

from a nyt article on the booming college admissions consulting business:

“It’s annoying when people complain about the money,” the Vermont-based counselor, Michele Hernandez, said. “I’m at the top of my field. Do people economize when they have a brain tumor and are looking for a neurosurgeon? If you want to go with someone cheaper, or chance it, don’t hire me.”

couldn't stop laughing.

Sunday, July 12, 2009

zone 1/2

finished my third shift in zone 1 at the SFGH ED, it was very busy (the way i like it) and full of new developments. one of the most surprising cases was a 55 F who came in c/o left flank pain, we thought that it was a UTI resistant to the ciprofloxacin that she was taking, but my ED attending suspected diverticulitis and the pt got an abdominal CT that revealed a right cystic ovarian mass concerning for ovarian cancer. after informing the patient of the CT results, I questioned the patient further and found that she has been experiencing abdominal bloating for two years and a sensation of abdominal fullness. she had never been pregnant. all of these symptoms (insidious and innocent as it seems) are all risk factors for ovarian cancer, and after the radiology results, things started clicking in place in a serious way. it was really sad.

working in the ED is nice, I really enjoy the fast pace and being busy busy busy while i am at the hospital (downtime is not as fun for me, although i do need my coffee ritual in the morning). the other aspect that i am really relishing is the speed of test results (labs, CT, etc), the decision-making and diagnosis, as well as discussing the plan with nurses, consult teams, attendings.

Friday, July 10, 2009

Needlestick update 1

Thanks everyone for the well wishes. :)

I went to occupational health this morning to have baseline labs drawn and consented to have a "student phlebotomist" draw my blood. hey, we all gotta learn somehow (although most of the time in med school phlebotomy class, the learning is mutual). the student phlebotomist was nervous, but pretty fast. after the blood draw, the nurse supervising her growled, "you have to make sure that the whole needle is in the sharps bin." we looked at the table and realized that the entire butterfly needle was still hanging outside the bin. Hm. The sight of such a needlestick hazard made me wince (on the inside).

Wednesday, July 08, 2009

"Stuck" in the ED

Yesterday was my first day in the SFGH ED as a sub-intern. I really enjoy the fast pace of the emergency room and the ability to triage and decide on preliminary tests for my patients. By the end of five hours, my head was pounding from the chaos and competing interests of different patients (next time, carry tylenol in my pocket).

Another nice thing about the ED is the number of procedures that you can do. By the end of my shift (7/7, 9:10 pm), I was attempting a lumbar puncture on a woman suspected to have meningitis. After inserting a 20-something gauge needle filled with lidocaine to anesthetize her back, I capped the needle using the one-handed scoop method. Then I tried to unscrew the needle to replace it with a longer needle in the LP kit. But the needle would not unscrew from the syringe. I made a twisting motion, which in retrospect only loosened the cap from the needle, and subsequently felt a familiar sting (after being phlebotomized by classmates so many times). I had stuck myself in the tip of my left index finger with a dirty needle.

"I think I stuck myself," I told the resident calmly, setting the syringe down and walking away from the patient while watching the blood welling underneath my glove tip. My first thought was, "Good thing we got a rapid HIV test before doing the LP." The resident was incredibly considerate and advised me to run my finger under running water for five minutes before calling the needlestick hotline (in retrospect, I would recommend washing with soap and water, running your wound under a faucet for 5 minutes, and maybe splashing some alcohol or betadine if you're extra paranoid).

While holding my finger under running water, I stared at the clock and began rapidly running through the patient's medical history again in my mind. 35 F c/o 3 days of fever and headache. 10/10 occipital headache with pain on neck flexion. no trauma. T 38.7 on arrival. What were her serologies? Is this an acute primary HIV infection? What is the NPV of a rapid HIV test in the SFGH ED? I felt unnaturally detached.

I was also extremely peeved at myself for making this mistake, because I usually pride myself on being careful during procedures. In fact, the smoldering annoyance has not faded today, and I still feel like an idiot. In retrospect, most needlestick injuries occur when you are recapping a needle (hence the scoop method) or disposing sharps, and the injury occured probably because I was attempting to unconsciously recap the needle before the needlepoint was exposed after seeing the cap slipping. Unfortunately, the lidocaine needle is a lot shorter than the IV needles that I have grown accustomed to using. When speaking to the ID fellow, he advised me that one of the most common needlestick injuries occur after screwing the needle too tightly into the syringe.

Needlesticks are extremely common in the hospital, but in the SFGH ED, it was especially scary. Most of my patients have HIV, HCV, or both, and this patient was a black box. It was also concerning for me to realize that we still had no idea what her diagnosis was.

Since today was my day off, I was able to read some personal accounts of other doctors and nurses who have joined the Private Misery Club and some of them are quite moving, funny, thoughtful, and some just depressing. Many talk about mortality, or the sensation of a lost future. Some of my first thoughts after the needlestick involved my future...what am i going to do now? can i practice medicine in the future? what about unprotected sex? and then maybe a few times I mentally uttered my favorite curse word of all time: fuck.

It is not a good time right now to wax philosophical about mortality or medicine; I have an appointment on Friday for some baseline labs. The patient's rapid oral HIV was negative, and I have been told today that her serologies were negative, but that doesn't ease my concern that this patient has acute primary HIV infection given her suspected meningitis (which can follow the prodromal flu-like illness) and considering our ED population enriched with blood-borne diseases. Argh. If there is one thing that I hate more than uncertainty or regret, it is having the patience and attention span required for surveillance serologies. The ED requires neither patience nor an attention span longer than 24 hours, which might still be ideal for me.

My favorite personal account of a needlestick injury is from Buckeye:
There's a nice one from an ED physician:
And a blithe one from an MS2: