A WhIRl of Activity

Finished my ED rotation last week and started my IR rotation at the VA this week...during the weekend I managed to complete two ED shifts while moving into a new apartment at Mission Bay!

Since this is my first time at the SF VA, there are a few observations:
- veterans tend to belong to a specific demographic
- veterans tend to pretty stoic about their medical conditions (example 1: "does this hurt?" [jab a needle] "Nope." example 2: "any medical problems?" "Nope." the note says he has HCV. These are two different veterans).
- the oceanside view is sublime
- the commute along the Great Highway is also pretty uplifting

Overhead, just heard a funny announcement over the loudspeaker:
"Mr. H. Mr. H, please return to your room, Room 1A."

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.

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.

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).

"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: http://ohiosurgery.blogspot.com/2008/10/needle-stick.html.
There's a nice one from an ED physician: http://gruntdoc.com/2005/05/needlestick.html
And a blithe one from an MS2: http://www.boston.com/yourlife/health/blog/2007/10/ill_have_what_s.html

perfect weekend

i'm not sure yet what "living the dream" means in medicine jargon, but just finished a perfect weekend (thanks to paul and costco):
saturday: philz coffee, driving over golden gate bridge to napa (mondavi, stag's leap -- cask 23 is uhmazing), napa outlets, spicy dinner in berkeley
sunday: philz coffee, casual walk to SF Giants game for $10 seats in the view box behind home plate, 9-hole game of golf at Golden Gate Park, and watching the movie "Up" in 3D using $7.50 costco tickets.

most people do not know where the heart is

recent study in BMC Family Practice showing that less than half of 722 Britons surveyed can identify where the heart is on a diagram.

http://www.cnn.com/2009/HEALTH/06/15/body.knowledge.survey/index.html

reminder to self: draw more pictures for patients

Radiology

Currently on a didactic radiology rotation for the next month. Medicine at SFGH was great, and I look forward to working in the ED next month (read: avoid the ED next month).

Currently watching basketball.

osborne wave!

Craig showed me the coooooolest EKG this morning of a 58 M "found down" in the tenderloin. rectal temp 24 degrees celsius. he had very large and distinct osborne waves!

It was very exciting to see real osborne waves for the first time, like reading someone's biography and then meeting them in person for the first time. Do people still read biographies?

Thanks, Craig!

reflections on a "stabbiversary"

extremely well-written reflection on near-death experiences from NYT blog. curiously, this author was stabbed in the neck with a stiletto 14 years ago...

"You can’t feel grateful to be alive your whole life any more than you can stay passionately in love forever — or grieve forever, for that matter. Time forces us all to betray ourselves and get back to the busywork of living in the world. Before a year had gone by the same dumb everyday anxieties and frustrations began creeping back. I’d be disgusted to catch myself yelling in traffic, pounding on my computer, lying awake at night wondering what was going to become of me."

http://happydays.blogs.nytimes.com/2009/06/02/reprieve/?em

"Winning the Game"

In medicine, "winning the game" means that a team or person has discharged all of their patients before the next call night, which means that they have no work until the next call. Clinical medicine is an interesting culture, with slang and neologisms that can roll off your tongue before you can think, "wait, that was incomprehensible to a normal person." For instance, you can say, "CBC q 6 hours, goal crit 30" or "cycle the trops" or "wean the nebs" and most people around you in the hospital will nod knowingly.

But i often digress. Medicine at el general has been great, I really enjoy working with my team and treating patients who are often underprivileged and have complex psychosocial situtations. The residents and attendings at SFGH are fantastic, and provide top notch care to patients who can easily fall between the cracks.

Medicine Sub-Internship

Currently a sub-I at SFGH, please don't get sick in the next month or you might see me.

Recently registered for step 2 USMLE.
Warning: CS costs $1,055 alone to register and CK costs $495. That doesn't include the mandatory travel to LA or lodging.

Recently bought an i-pod touch to enjoy epocrates...my first apple product. Got absorbed in installing apps and was reading through Yelp, found out that there are many patient reviews of UCSF Medical Center. It's so interesting read those reviews, which are either 1 star or 5 star (max)...which makes sense since you only make the effort to type something if you are extremely satisfied or ridiculously angry.

Some observations of Yelp feedback: Interestingly, the polarized reviews had many themes in common. The 1-star patients usually are in general good health with minimal contact with healthcare, coming in with a musculoskeletal complaint (eg xray for foot/hand, sprain or acute flu with SOB) to Urgent Care (oohh, lots of ire). The main complaint is waiting time (up to 8 hrs) in the ED, brusque staff, lack of parking, billing, hospital food, etc. There were very few complaints about doctors' care (except for one woman who was turned away by an ED physician for SOB), and no complaints about residents or trainees (except one patient cited the lack of continuity with residents in clinic).

Patients who write 5-star reviews generally have serious/chronic/rare ongoing medical conditions. Some families will write on behalf of patients. One reviewer wrote on behalf of a friend who had heart surgery, another patient was grateful for the teaching program regarding kidney transplants, etc. One patient noted that the lab reports for rare diseases will be processed faster at UCSF than at other hospitals. Some patients who had life-threatening conditions praised the ED.

Reading that uncensored feedback might be a good exercise for our hospital administration to see what can be improved. We can score big points with patients if we make the logistics of getting healtcare more convenient -- making appointments online and keeping clinic wait times within 1-2 hrs (or the pizza is free!).

Friendly PSA

Call your mother today!

Remember that the US postal service raises prices on stamps to 44 cents tomorrow!

Reflections on Third Year

"So what should I know for third year?" someone asked me recently.

Whoa. Wow. Um. Where to begin?

Undoubtedly, the third year of medical school has been the most memorable experience thus far in my life, and even now when I reflect on all the crazy and outrageous and wonderful and awful things that I've seen, I can't even believe that it happened to me and not some 2D person on "Grey's Anatomy." In psychiatry, they might call that derealization.

Being a third year medical student is like being a guppy in the hospital ocean. You wander around helplessly, trying to learn how to coexist in a complex environment under some very talented and harried residents. It can be totally confusing and bewildering, but it also opens the door to levels of opportunity and privileged intimacy with strangers previously unheard of. Sometimes, third year feels like an apprenticeship where you learn things using your hands and watching others. Other times, it can feel like boot camp or pledging a fraternity. In many ways, you learn things about yourself and other people during your first year on the wards...and none of these lessons can be easily transmitted verbally...it's almost like everyone has to undergo a second awkward adolescent period as a rite of passage. Also, being a third year medical student was like regressing back into being a 4-year-old child, because the medical world is often alien to the newcomer and learning how to be a doctor is like learning how to be an adult all over again...how to speak medical jargon in surgery vs. psychiatry, how to be polite (pager etiquette), how to follow rules, how to learn what might be important (lab values, complaints) and what is unimportant when listening to a story -- simple things that seem obvious to the indoctrinated.

What also amazed me was how simply being a third year student opened doors in the hospital... From being a mere college graduate with an interest in medicine to someone invited to scrub in on surgeries, write notes, interview patients, perform IV insertions and intubations, and witness the miracle of birth...I learned halfway through third year that simply saying, "I'm a medical student, can I watch?" led me to opportunities beyond imagination.

Third year is hard, I definitely feel slightly burned out, but surprisingly my cynicism has not worsened. If anything, I've shed a little bit of my "beat around the bush" mentality. It was more difficult to blog about third year than anticipated, mostly because of time constraints but also because of privacy issues (HIPAA etc). If I had more time, I would write out paragraphs of my ten most memorable experiences this past year, but instead will list them in no particular order:

1) participating in a liver donor run to New Mexico over Thanksgiving
2) scrubbing in on liver transplants
3) befriending a boy with a giant retroperitoneal tumor in rad onc and crying outside the OR after hearing that it was wrapped around his aorta
4) taking care of little kids in peds urgent care
5) watching babies being born in fresno
6) inserting a 14-gauge IV into the dorsal hand vein of a patient under the curtain on anesthesia
7) chasing after a psychotic HIV+ transgendered patient at SF General on psychiatry
8) participating in my first code while scrubbed in on a vascular surgery in which the patient had an MI on the table...he was placed on ECMO
9) learning from medicine to "always do what's right for the patient" and to talk to unconscious patients as though they were awake, even though it seems strange, it's a sign of respect.
10) watching the work-up of a patient who turned out to have Q fever endocarditis

Philz Coffee

For the past few weeks, Paul and I have been addicted to Philz Coffee. Seriously addicted. My favorite is "Anesthesia to the Upside," because it's very mellow, sweet, and nutty. Other good ones are Ambrosia, Tesora, and Aromatic Arabic (dark roast).

http://www.philzcoffee.com/

At first sip, you will fall in love and get a huge caffeine rush. I've never had coffee that was so flavorful and well-blended, and they make each cup one at a time with heavy cream and brown sugar.

The mini donuts are also tasty, especially Meyer Lemon.

There's a new store in Palo Alto, too! :)

Go drink coffee now! And then eat BiRite ice cream! :)

Do Not Use Dirty Needles

My neuro ICU patient is currently suffering from MRSA bacteremia and endocarditis, with mycotic aneurysms in her brain causing intracranial hemorrhages. She is an IV drug user with hepatitis C and she's 30 years old.

After seeing many patients with a history of IV drug use, a staggering proportion of patients have hepatitis C, HIV, or both. Many patients have infections from dirty needles, like my patient.

Kids, just say no to drugs. But please, do NOT INJECT DRUGS. It's possibly the worst imaginable method of ingesting substances for tons of reasons (outlined below), but it also happens to give people the quickest and most intense effect (partly because it increases bioavailability by bypassing the gut). It's impressive to me that much of the morbidity arising from IV drug use (IVDU) arises from using dirty needles...
- Hepatitis C - very common
- HIV - pretty common
- MRSA, infections, etc
- higher risk of overdose
- nerve/artery damage

Never use needles. Stay away from drugs. Can you tell that I'm venting?

Psych!

"Third year sucks," an intern once told me in the middle of third year.

"Really? Why?" I said (wow, way to go, Stephanie).

"Because you're constantly changing into different clinics and doing different roles and working with new people with no idea how to think or what to expect until you get the hang of it after a few days and then you're shoved into a totally new setting with a different set of practices. And the whole time that you're struggling, everyone around you is critically judging you."

Never really considered that, but it's a good synopsis of why third year can be challenging. The other aspect not really mentioned is that third year can be hard because there is a huge lack of personal free time and a sense of social isolation compared to the first two years of medical school. But it's not all bad news, ladies and gents.

Once you get the hang of third year, however, it can be exciting and fun! Imagine going to a chocolate salon and sampling every bite of chocolate. That was fun last week, until I got really nauseous.

Third year is like a cultural safari where you can study different tribes, adopt their customs, and learn how they think and what their values are. For someone who is adventurous and flexible, resourceful and resilient, third year is like a grueling backpacking trip through the Amazon where the locals are concurrently evaluating whether or not you should be allowed to go traveling. But the best part is that you don't have to travel very far at all...in fact, you tend to stay in one building for 13 hours per day.

Another interesting group that you get enormous exposure to is your patients. I have always suspected this before, but the strength of any medical training (and thus medical school) is heavily based upon both the skills of the residents AND the diversity of your patient population. Pick a medical school based on geography and the patient population that you get exposure to, because that will shape your training as a doctor. At UCSF, we are enormously privileged to have several settings (VA, Moffitt, SFGH, CPMC, Fresno) that gives us a wide range of patients from all walks of life....young/old, rich/poor, urban/rural, etc/etc. Working at SFGH has been an amazing experience, because it is the only hospital in the city that serves the uninsured, the only trauma center in SF, and the cradle of HIV/AIDS healthcare. It is estimated that up to 25% of the patients at SFGH are HIV+ and SFGH is home to Ward 86, one of the most renowned HIV clinics in the country. Going to medical school in SF allows you the unbelievable privilege of working with a large HIV+ population in SF and gives you insight and medical training that cannot be replicated, and I never TRULY appreciated this until third year.

Okay, I've totally digressed again. All of this was a prelude to a short reflection on my time on inpatient psychiatry at SFGH. It was an excellent experience, and I learned so much about how to interview psychiatric patients (be nonjudgmental, ask questions like Columbo) and how to think/adminster psychiatric medications. In fact, the inspiration for this posting was a recent UCSF news tidbit on how the drug company Eli Lilly is trying to market a new combo drug (olanzapine and prozac) for treatment-resistant depression. Psych is so incredibly interesting, and I predict big advances in the next 50-100 years as we learn more about the pathophysiology of schizophrenia, bipolar, depression.

Oops, gotta go.

hey, i got my stuff back

Believe it or not...but I got a call from a medical classmate letting me know that my stolen tote bag was dropped off "by a homeless guy" at the Moffitt ED. Most of my stuff was still there (!) including:

- psychiatry case files book
- medical student ID
- stethoscope
- reflex hammer
- key
- pager
- two notebooks
- chapstick
- umbrella

The only things missing that i can tell so far were a cliff bar, the battery from my pager, and a pack of 50 cards for 1-800 quit tobacco. Found objects include a BART card and a flyer for a tattoo parlor.

Not sure what to make of this...maybe the man who smashed my car window realized that he stole a bag from a painfully dorky medical student and took pity on me?

boosts

Last night my car window was broken and my book bag taken as I was eating dinner in SOMA. Bummer. Like any curious medical student, I started almost compulsively googling some background reading and found that these car burglaries or "smash and grab" crimes (known as "boosts") are way too common in San Francisco, with an average of 41 incidents per day in the city!

Many medical students have experienced car burglaries even in the Sunset, which is relatively safe, and some have had their cars stolen. It's like owning a bicycle in college....it WILL get stolen! Accepting these crimes as a fact of life is frustrating.

Interestingly, after a campaign to crack down on car burglaries, the police reported that "the team has arrested 34 people, according to department spokesman Sgt. Steve Mannina, which has contributed to a 22 percent drop in incidents reported between October of this year and October 2006."

"By arresting one person, we prevent at least 10 to 20 [break-ins] per week,” Lazar said. “One person doesn’t break into just one car. They move on and target more.”

This week, my car window got broken and I lost all of my psychiatry materials.

Last week, a psychiatric patient escaped from the hospital under my supervision...but he came back six hours later to "get his stuff back"!

Sigh.

Mnemonic for EKG Lead Placement

Today in anesthesiology, I helped out with the setup for a patient undergoing a whipple procedure for pancreatic cancer. the surgery lasted all day (roughly 8-5pm) and was pretty complex, plus there was a really amazing resected specimen (part of the pancreas, duodenum, with a huge yellow globular tumor). slices of the tumor were sent to a tissue bank and the rest was sent to pathology. but i digress.

after the whipple man was well underway, i tagged along and observed four IVF procedures in which eggs were being harvested from hormonally primed women. then i bounced back to the OR to help set up 2 more patients for a D&C and TVH.

slowly, i am starting to learn how to think like an anesthesiologist. also, i am starting to figure out the myriad of procedures that have to be done in a hurry. during the IVF procedures, it was amazing to think about how marvelous noninvasive inventions like the EKG, pulse oximeter, and even an O2 nasal cannula with CO2 monitors can improve patient safety without harming the patient at all. anesthesia itself has always amazed me...how can a person go to sleep, have their abdomen exposed, have a tumor resected with their plumbing all reconnected...and wake up with minimal pain (thanks to an epidural), alive and kicking? the miracle of anesthesia. amen.

oh wait, i forgot about the title of this post.

so the EKG leads in the OR have 5 leads. on the left side, the resident taught me the mnemonic "smoke over fire," meaning that the red lead is below the black lead (and the brown lead is in between, pretend it's wood if it makes you feel better). on the right side, the green lead is below the white lead, so I have decided to make my own mnemonic: "snow falling on cedars." okay, okay, I know that the biggest criticism of my MSP lessons (based on comments in Evalue) was that I was heavy on the mnemonics, but there are oodles of things in medicine that don't have any intrinsic meaning...like why the white lead has to be white...and why i am spending time typing this ramble when I should be sleeping....zzzz...