Mike and I were trading stories about medical cases that we've seen recently. My fault, really, since I'm obsessed with medicine and can't stop talking about work (since that's all I do anymore, anyway). After I told Mike about my current patient with weight loss of unknown origin and a recent case of Q fever endocarditis, Mike told me the following pediatrics case that he saw today:
"Six-year-old boy, the story is that he took a dump this morning and it was bright red. No stomach pain, might have had a similar poop last night, no vomiting, heart rate is stable, no signs of dehydration or shock, kid is in no apparent distress."
"INTUSSUCEPTION!" I yell.
"No. So the resident does a digital rectal exam, and his glove comes out bright red and covered in poo. The resident smears his glove on a FOBT (a strip of paper that turns color when poo with blood gets smeared on it, even if the blood is not visible to the naked eye), and the strip never changes color."
"The strip should change color," I said, "so either the strip is defective or it's not really blood."
"Right, but what is it?"
"Meckel's?" I said.
"No. Then we asked the boy to pee in a cup. Why?"
"To check for hematuria or proteinuria?"
"No, even simpler."
"To see if his pee is red too?"
"Yes! Because eating too many beets can color your poop and your pee."
"Was it red?" I asked.
"No, his urine was not red."
"GI bleed?" I said, "he doesn't seem to be in distress. He's too young for colon cancer, diverticulitis, or ulcers.
"No. Give up?" Mike asked.
Yes.
"So the resident is totally clueless. We talk to the attending, and the attending laughs. He says that a couple years ago, when RED HOT CHEETOS hit the market, there was a huge outbreak of kids with bright red poo. And this was the case."
Wednesday, August 13, 2008
Friday, August 08, 2008
"that's all i can do"
Mr. D suffered from the lung disease that killed Evel Knievel -- idiopathic pulmonary fibrosis (IPF). The word "idiopathic" in medicine is a code word that means "doctors have no clue what the cause of the disease can be." As a result, Mr. D couldn't breathe anymore -- his lungs were like a pair of old dishwashing sponges left in the sun to dry. Needless to say, there wasn't much oxygen exchange happening. So Mr. D got a lung transplant -- just one lung because organs are in short supply and that's actually sufficient for someone to live. When you have a new organ, you have to take lots of drugs to keep your immune system down so that it doesn't reject the new heart/lung/kidney, but that also renders you susceptible to millions of germs and bacteria that would otherwise be harmless. So Mr. D came down with a fungal infection -- Aspergillus -- and a bacterial infection -- Pseudomonas.
When Mr. D came to the hospital for a short procedure, he seemed okay. It was interesting listening to his lungs, because his right lung (the "native" one with IPF), sounded like tissue paper crackling. His left lung had normal breath sounds. It was listening to two different lungs in one person. I was immediately struck by how equanimous Mr. D was, especially when I asked him if it was okay for a group of medical students to come by and listen to his interesting physical exam. He was a quiet, scholarly guy in his 50s with graying hair -- the type of patient with glasses and a copy of the New York Times on his bed.
After I switched services, Mr. D was ready to go home when something nearly catastrophic happened. He developed a massive bleed into the space behind his back -- his retroperitoneal space. The bleed was idiopathic. Mr. D landed in the ICU and suffered from acute renal failure --- his kidneys were in trouble.
A few days ago, I saw Mr. D while walking through the ICU and dropped by to say hello. Mr. D looked pale and sick, his head was tilted to one side, but he was still conversant. I nervously eyed a length of tubing filled with blood emerging from his body -- he was on CVVH, which filters the blood and helps out by mimicking the kidney. The doctors were thinking that he might need to go on dialysis for the rest of his life.
"Hang in there, Mr. D," I chirped.
He looked at me with tired eyes filled with weary, stubborn resignation.
"That's all I can do," he said softly.
When Mr. D came to the hospital for a short procedure, he seemed okay. It was interesting listening to his lungs, because his right lung (the "native" one with IPF), sounded like tissue paper crackling. His left lung had normal breath sounds. It was listening to two different lungs in one person. I was immediately struck by how equanimous Mr. D was, especially when I asked him if it was okay for a group of medical students to come by and listen to his interesting physical exam. He was a quiet, scholarly guy in his 50s with graying hair -- the type of patient with glasses and a copy of the New York Times on his bed.
After I switched services, Mr. D was ready to go home when something nearly catastrophic happened. He developed a massive bleed into the space behind his back -- his retroperitoneal space. The bleed was idiopathic. Mr. D landed in the ICU and suffered from acute renal failure --- his kidneys were in trouble.
A few days ago, I saw Mr. D while walking through the ICU and dropped by to say hello. Mr. D looked pale and sick, his head was tilted to one side, but he was still conversant. I nervously eyed a length of tubing filled with blood emerging from his body -- he was on CVVH, which filters the blood and helps out by mimicking the kidney. The doctors were thinking that he might need to go on dialysis for the rest of his life.
"Hang in there, Mr. D," I chirped.
He looked at me with tired eyes filled with weary, stubborn resignation.
"That's all I can do," he said softly.
satire on intellectual pretension
NYT yesterday, the most amusing, hilarious, mockingly pseudo-intellectual satire that I've read in a while. There are some valid points...have we become a society that values the aggregator over the creator? Is the mode of information delivery more important or prestigious than the information itself?
Lord of the Memes
By DAVID BROOKS
Published: August 7, 2008
Dear Dr. Kierkegaard,
All my life I’ve been a successful pseudo-intellectual, sprinkling quotations from Kafka, Epictetus and Derrida into my conversations, impressing dates and making my friends feel mentally inferior. But over the last few years, it’s stopped working. People just look at me blankly. My artificially inflated self-esteem is on the wane. What happened?
Existential in Exeter
Dear Existential,
It pains me to see so many people being pseudo-intellectual in the wrong way. It desecrates the memory of the great poseurs of the past. And it is all the more frustrating because your error is so simple and yet so fundamental.
You have failed to keep pace with the current code of intellectual one-upsmanship. You have failed to appreciate that over the past few years, there has been a tectonic shift in the basis of good taste.
You must remember that there have been three epochs of intellectual affectation. The first, lasting from approximately 1400 to 1965, was the great age of snobbery. Cultural artifacts existed in a hierarchy, with opera and fine art at the top, and stripping at the bottom. The social climbing pseud merely had to familiarize himself with the forms at the top of the hierarchy and febrile acolytes would perch at his feet.
In 1960, for example, he merely had to follow the code of high modernism. He would master some impenetrably difficult work of art from T.S. Eliot or Ezra Pound and then brood contemplatively at parties about Lionel Trilling’s misinterpretation of it. A successful date might consist of going to a reading of “The Waste Land,” contemplating the hollowness of the human condition and then going home to drink Russian vodka and suck on the gas pipe.
This code died sometime in the late 1960s and was replaced by the code of the Higher Eclectica. The old hierarchy of the arts was dismissed as hopelessly reactionary. Instead, any cultural artifact produced by a member of a colonially oppressed out-group was deemed artistically and intellectually superior.
During this period, status rewards went to the ostentatious cultural omnivores — those who could publicly savor an infinite range of historically hegemonized cultural products. It was necessary to have a record collection that contained “a little bit of everything” (except heavy metal): bluegrass, rap, world music, salsa and Gregorian chant. It was useful to decorate one’s living room with African or Thai religious totems — any religion so long as it was one you could not conceivably believe in.
But on or about June 29, 2007, human character changed. That, of course, was the release date of the first iPhone.
On that date, media displaced culture. As commenters on The American Scene blog have pointed out, the means of transmission replaced the content of culture as the center of historical excitement and as the marker of social status.
Now the global thought-leader is defined less by what culture he enjoys than by the smartphone, social bookmarking site, social network and e-mail provider he uses to store and transmit it. (In this era, MySpace is the new leisure suit and an AOL e-mail address is a scarlet letter of techno-shame.)
Today, Kindle can change the world, but nobody expects much from a mere novel. The brain overshadows the mind. Design overshadows art.
This transition has produced some new status rules. In the first place, prestige has shifted from the producer of art to the aggregator and the appraiser. Inventors, artists and writers come and go, but buzz is forever. Maximum status goes to the Gladwellian heroes who occupy the convergence points of the Internet infosystem — Web sites like Pitchfork for music, Gizmodo for gadgets, Bookforum for ideas, etc.
These tastemakers surf the obscure niches of the culture market bringing back fashion-forward nuggets of coolness for their throngs of grateful disciples.
Second, in order to cement your status in the cultural elite, you want to be already sick of everything no one else has even heard of.
When you first come across some obscure cultural artifact — an unknown indie band, organic skate sneakers or wireless headphones from Finland — you will want to erupt with ecstatic enthusiasm. This will highlight the importance of your cultural discovery, the fineness of your discerning taste, and your early adopter insiderness for having found it before anyone else.
Then, a few weeks later, after the object is slightly better known, you will dismiss all the hype with a gesture of putrid disgust. This will demonstrate your lofty superiority to the sluggish masses. It will show how far ahead of the crowd you are and how distantly you have already ventured into the future.
If you can do this, becoming not only an early adopter, but an early discarder, you will realize greater status rewards than you ever imagined. Remember, cultural epochs come and go, but one-upsmanship is forever.
Lord of the Memes
By DAVID BROOKS
Published: August 7, 2008
Dear Dr. Kierkegaard,
All my life I’ve been a successful pseudo-intellectual, sprinkling quotations from Kafka, Epictetus and Derrida into my conversations, impressing dates and making my friends feel mentally inferior. But over the last few years, it’s stopped working. People just look at me blankly. My artificially inflated self-esteem is on the wane. What happened?
Existential in Exeter
Dear Existential,
It pains me to see so many people being pseudo-intellectual in the wrong way. It desecrates the memory of the great poseurs of the past. And it is all the more frustrating because your error is so simple and yet so fundamental.
You have failed to keep pace with the current code of intellectual one-upsmanship. You have failed to appreciate that over the past few years, there has been a tectonic shift in the basis of good taste.
You must remember that there have been three epochs of intellectual affectation. The first, lasting from approximately 1400 to 1965, was the great age of snobbery. Cultural artifacts existed in a hierarchy, with opera and fine art at the top, and stripping at the bottom. The social climbing pseud merely had to familiarize himself with the forms at the top of the hierarchy and febrile acolytes would perch at his feet.
In 1960, for example, he merely had to follow the code of high modernism. He would master some impenetrably difficult work of art from T.S. Eliot or Ezra Pound and then brood contemplatively at parties about Lionel Trilling’s misinterpretation of it. A successful date might consist of going to a reading of “The Waste Land,” contemplating the hollowness of the human condition and then going home to drink Russian vodka and suck on the gas pipe.
This code died sometime in the late 1960s and was replaced by the code of the Higher Eclectica. The old hierarchy of the arts was dismissed as hopelessly reactionary. Instead, any cultural artifact produced by a member of a colonially oppressed out-group was deemed artistically and intellectually superior.
During this period, status rewards went to the ostentatious cultural omnivores — those who could publicly savor an infinite range of historically hegemonized cultural products. It was necessary to have a record collection that contained “a little bit of everything” (except heavy metal): bluegrass, rap, world music, salsa and Gregorian chant. It was useful to decorate one’s living room with African or Thai religious totems — any religion so long as it was one you could not conceivably believe in.
But on or about June 29, 2007, human character changed. That, of course, was the release date of the first iPhone.
On that date, media displaced culture. As commenters on The American Scene blog have pointed out, the means of transmission replaced the content of culture as the center of historical excitement and as the marker of social status.
Now the global thought-leader is defined less by what culture he enjoys than by the smartphone, social bookmarking site, social network and e-mail provider he uses to store and transmit it. (In this era, MySpace is the new leisure suit and an AOL e-mail address is a scarlet letter of techno-shame.)
Today, Kindle can change the world, but nobody expects much from a mere novel. The brain overshadows the mind. Design overshadows art.
This transition has produced some new status rules. In the first place, prestige has shifted from the producer of art to the aggregator and the appraiser. Inventors, artists and writers come and go, but buzz is forever. Maximum status goes to the Gladwellian heroes who occupy the convergence points of the Internet infosystem — Web sites like Pitchfork for music, Gizmodo for gadgets, Bookforum for ideas, etc.
These tastemakers surf the obscure niches of the culture market bringing back fashion-forward nuggets of coolness for their throngs of grateful disciples.
Second, in order to cement your status in the cultural elite, you want to be already sick of everything no one else has even heard of.
When you first come across some obscure cultural artifact — an unknown indie band, organic skate sneakers or wireless headphones from Finland — you will want to erupt with ecstatic enthusiasm. This will highlight the importance of your cultural discovery, the fineness of your discerning taste, and your early adopter insiderness for having found it before anyone else.
Then, a few weeks later, after the object is slightly better known, you will dismiss all the hype with a gesture of putrid disgust. This will demonstrate your lofty superiority to the sluggish masses. It will show how far ahead of the crowd you are and how distantly you have already ventured into the future.
If you can do this, becoming not only an early adopter, but an early discarder, you will realize greater status rewards than you ever imagined. Remember, cultural epochs come and go, but one-upsmanship is forever.
Monday, August 04, 2008
Heart Attack? Do This Now.
Working on the cardiology service, here is my public service announcement on heart attacks adapted from http://www.health.com/health/condition-article/0,,20188758,00.html
"If you are having chest pain and you do not have nitroglycerin:
1) Call 911 or other emergency services now. Describe your symptoms, and say that you could be having a heart attack.
2) Stay on the phone. The emergency operator will tell you what to do.
3) After you call for help, chew one regular-strength uncoated aspirin. Aspirin helps keep blood from clotting, so it may help you survive a heart attack.
The best choice is to go to the hospital in an ambulance. The paramedics can begin lifesaving treatments even before you arrive at the hospital. If you cannot reach emergency services, have someone drive you to the hospital right away. Do not drive yourself unless you have absolutely no other choice."
"If you are having chest pain and you do not have nitroglycerin:
1) Call 911 or other emergency services now. Describe your symptoms, and say that you could be having a heart attack.
2) Stay on the phone. The emergency operator will tell you what to do.
3) After you call for help, chew one regular-strength uncoated aspirin. Aspirin helps keep blood from clotting, so it may help you survive a heart attack.
The best choice is to go to the hospital in an ambulance. The paramedics can begin lifesaving treatments even before you arrive at the hospital. If you cannot reach emergency services, have someone drive you to the hospital right away. Do not drive yourself unless you have absolutely no other choice."
Sunday, August 03, 2008
the.most.awesome.bedroom.ever.
from BIDMC CEO Paul Levy's blogBoston's Fenway Park on a bedroom mural! Can I get one for my future kid?? This mural is so awesome! You could get little sox player dolls and stick them on the bases -- too bad the Manny doll was lost. At least he went to my hometown Dodgers...
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."
"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. :(
http://www.cmu.edu/homepage/beyond/2008/summer/an-enduring-legacy.shtml
In other news, Randy Pausch passed away on Friday, 7/25. Sad sad news. :(
http://www.cmu.edu/homepage/beyond/2008/summer/an-enduring-legacy.shtml
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"
- "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?"
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:
CASE REPORT
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.
ABSTRACT
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
CASE REPORT
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.
ABSTRACT
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).
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."
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
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.
"Yes."
"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..."
...my vitals were HR 99, BP 150/90, RR 22
..."JUST KIDDING, STEPH!"
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....
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.
"Yes."
"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..."
...my vitals were HR 99, BP 150/90, RR 22
..."JUST KIDDING, STEPH!"
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....
Monday, June 30, 2008
Great Weekend
One of my best friends from high school came to visit me in SF last weekend, and we drove to check out Stanford Business School for him before going to an 80s cover band concert on Friday night. The next morning, we biked around the perimeter of Angel Island, which was reachable by ferry and surprisingly lovely. The bike ride took about 1.5 hours, and the best part was how you could get a 360 degree view of San Francisco bay and how each part of the path gave you a slightly different by no less breathtaking view of the colorful houses, blue water, and white sailboats. I liked how the scenic view changed as you labored around the island, the changing nature was perhaps one of my favorite parts. It's weird, I told Leo, how after we visited Alcatraz 2 years ago, that I would not visit Alcatraz more than once, but I would definitely visit Angel Island again.
On Sunday, we visited Napa and tasted wine at Freemark Abbey, Louis Martini (hands down the best cabs in terms of taste & value, all 5 wines were amazing and I couldn't dump a single drop), V Sattui, Mondavi, and Opus One (ridiculous and excellent $30 tasting of one extremely hyped- up wine). We also saw the view from Artesa.
Today in medicine, it made me happy to think that only yesterday I was in Napa. :-)
Thursday, June 26, 2008
Gone Baby Gone II
Learned from a fellow medical student that the baby from my first delivery ever died a few weeks ago. It was a huge jolt, because I never expected the baby to die, even though his Apgars (assigned by me after some review with the peds team) were 3, 4, and 6. I assumed that he was going to make it after watching him for almost 10 hours after he was born, and now he has become my first peds patient to pass away.
Peds vs. Surgery
Notable quotes
...from peds: a boy in clinic with penis pain says that his "peanuts" hurts...Awww!
...from a friend in surgery: a resident who barks, "THERE'S NO TIME FOR TEACHING, ONLY LEARNING."
...from peds: a boy in clinic with penis pain says that his "peanuts" hurts...Awww!
...from a friend in surgery: a resident who barks, "THERE'S NO TIME FOR TEACHING, ONLY LEARNING."
Saturday, June 14, 2008
Pausch's Last Lecture
Four days of fever, 1 day of sore throat, and 1 day of recovery (6 days total) and I'm back to baseline....wow, that took way longer than expected. :( I'm a little bummed that my 2-week summer vacation was cut in half by a pediatric viral illness, but I'm glad that it happened at a "convenient" time (so to speak) when there was not much going on and no patients to see.
Talking to my roommate made me realize that there are different senses of the word "sick," there's the conversational "sick" when you have sniffles or a mild URI. Then there's the second-level "sick," when you can't get out of bed and feel truly miserable and incapacitated for a short while and remember how much it sucks to not be healthy. There's also "sick" in the sense of mental illness, which is chronic and difficult to describe and quantify, and there's also the profound sense of "sick," usually earning you that "coveted" admission to the hospital because one of your organs is failing, or you need surgery with dorky UC med students watching, or sometimes because you are dying.
Most people on the web have heard of Randy Pausch, PhD, the professor at Carnegie Mellon University dying from pancreatic cancer who gave a stirring "Last Lecture" about life lessons. A few months ago, I learned about him from an interview in Time magazine, but didn't bother to Google his lecture until a friend in pharmacy school told me about it in the laundry room today. You can watch it on Google videos, it's a bit long (76 minutes), but worth the investment.
Naturally, I was interested because Randy is a pancreatic cancer patient, and if you don't read my blog that often, I am interested in pancreatic cancer research. Different cancers have different mortality rates, but pancreatic cancer remains a fearsome predator among cancers with a median survival of 6 months depending on how far the tumor spreads.
Oncology keeps drawing me closer, but still no idea. I told my friend in the laundry room that I'm interested in oncology because it's work that continually reminds me by its very nature why I am working and what really matters in this life. Somehow, by working with pancreatic cancer patients who continually face this duel with death, I feel like oncology motivates me to work even harder and with more purpose. Paradoxically and more importantly, oncology also simultaneously inspires me to appreciate everything non-work related in life -- family, friends, food, food, creature comforts, beautiful moments, holidays, and the ease of health. How can anything else teach me so elegantly to value both work and everything non-work?
Dr. Pausch's video: http://video.google.com/videoplay?docid=-5700431505846055184
Dr. Pausch's homepage: http://download.srv.cs.cmu.edu/~pausch/
Talking to my roommate made me realize that there are different senses of the word "sick," there's the conversational "sick" when you have sniffles or a mild URI. Then there's the second-level "sick," when you can't get out of bed and feel truly miserable and incapacitated for a short while and remember how much it sucks to not be healthy. There's also "sick" in the sense of mental illness, which is chronic and difficult to describe and quantify, and there's also the profound sense of "sick," usually earning you that "coveted" admission to the hospital because one of your organs is failing, or you need surgery with dorky UC med students watching, or sometimes because you are dying.
Most people on the web have heard of Randy Pausch, PhD, the professor at Carnegie Mellon University dying from pancreatic cancer who gave a stirring "Last Lecture" about life lessons. A few months ago, I learned about him from an interview in Time magazine, but didn't bother to Google his lecture until a friend in pharmacy school told me about it in the laundry room today. You can watch it on Google videos, it's a bit long (76 minutes), but worth the investment.
Naturally, I was interested because Randy is a pancreatic cancer patient, and if you don't read my blog that often, I am interested in pancreatic cancer research. Different cancers have different mortality rates, but pancreatic cancer remains a fearsome predator among cancers with a median survival of 6 months depending on how far the tumor spreads.
Oncology keeps drawing me closer, but still no idea. I told my friend in the laundry room that I'm interested in oncology because it's work that continually reminds me by its very nature why I am working and what really matters in this life. Somehow, by working with pancreatic cancer patients who continually face this duel with death, I feel like oncology motivates me to work even harder and with more purpose. Paradoxically and more importantly, oncology also simultaneously inspires me to appreciate everything non-work related in life -- family, friends, food, food, creature comforts, beautiful moments, holidays, and the ease of health. How can anything else teach me so elegantly to value both work and everything non-work?
Dr. Pausch's video: http://video.google.com/videoplay?docid=-5700431505846055184
Dr. Pausch's homepage: http://download.srv.cs.cmu.edu/~pausch/
Friday, June 13, 2008
Happy Graduation, Matthew!
My little brother Matthew is graduating from Arcadia High School today!Congratulations, Matthew!
Pictured with his prom date, but don't worry ladies, he's single! (as far as we know)
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