Waxing Poetic

Well, it's finally arrived. My big transition, the great leap, the fall, tipping into the abyss, the milestone, the ceremony, crossing the rubicon: graduation. Three weeks from now, I'll be more than just tyro (novice), I'll be tyro, MD.

In honor of this occasion, I'd like to try and figure out what the color attributed to each degree means. We all have separate colors, see. My hood should be black with 5 inches of forest green velvet trim. Sweet. I'm wearing it to the gym, I don't care if it's typically only worn to commencement or the encaenia (doubly sweet! Who goes to those things?)

forest green: MD. Obviously, this means we're a loving, caring profession that is a welcoming and nurturing as Gaia, the earth goddess. We continue to grow in our knowledge as we seek to propagate the growth of all. Alternatively, one could comment that the medical profession is like a terrifying forest at night full of hungry wolves waiting to stick tubes down your throat or lines in your subclavian vein. Ask me again after internship.

purple: Law. I wasn't surprised to discover that purple comes from the Latin purpura, as in 'manifestation of a terrible systemic disease that will kill you shortly'. If I see purpura on a patient, I should think of overwhelming sepsis or meningitis. I will leave the fair reader to draw their own conclusions about the similarities and differences between lawyers and dread systemic diseases. Alternatively, I may be a tad unfair. It may just be that purple, associated with royalty from antiquity, represents how lawyers are only available to the wealthy. Oh, sorry--I was supposed to be positive with that one. I suppose everyone has their growing edges.

silver: oratory, speech (i.e., politics).I didn't make this up, from the silver article on wikipedia:

Silver is the most popular color for automobiles because police surveys have shown that because silver is a bright color, silver automobiles are involved in crashes less often than cars of any other color.
Now, if that doesn't describe a politician, I don't know what does.

So I guess our colors do help define us. Good thing we wear those hoods.


The Female of The Species

In reference to this post:
Rudyard Kipling's Verse By Rudyard Kipling:
"...the Himalayan peasant meets the he bear in his pride
He shouts to scare the monster who will often turn aside
But the she bear thus accosted rends the peasant tooth and nail
For the female of the species is more deadly than the male"

A comment on the momma bear post brought Kipling up as a previous observation that there is something to mother's instinct that defies logic or expectations. Although Kipling's work does wax a bit dated, it bears out the same observation.


For the Dearly Departed

Worth reading: a post at a great blog about the price some first-responders pay to help out.

White Cloud?

Crap, it didn't work. I guess fate doesn't listen after all. I'm going to bed now, that'll do it.

White Cloud

I'm hoping that in writing this I will tempt the fates enough to bring me an admission. I'm a white cloud right now, and I'm stuck on call blogging rather than working. Now, this might seem like a bit of a crazy request; but when my wife is home in bed taking care of three kids, I kind of want my time away to be, oh, I don't know, somehow productive.

The first time I realized that I was actually superstitious was an overnight trauma call. We had seen a penetrating chest wound that didn't survive, a car accident that included a whole family that did, and a five-hundered pound Amyand's hernia, which occurs when a Meckel's diverticulum incarcerates into a hernia sack and then ruptures, causing necrosis and serious badness if not removed. Even the chief, who was amazingly resiliant, was exhausted, breaking between stitches to roll his shoulders back and look at the ceiling. As we finished up the case, I said, 'well, at least it's quiet now, right?'

He looked at me as only med students can be looked at, for we have yet to learn the ways of doctoring that matter. Never, ever, ever, tempt the fates, for they will deliver. We had three more traumas not thirty minutes later, just in time to push morning rounds back by hours. I couldn't feel my feet. And while that night was the night that helped me pick my speciality, I was tired and I wanted to go home. I had made myself into a typhoon cloud.

In contrast, here on my medicine rotation, I'm a white cloud on a breezy blue-sky day, footloose and fancy-free. Life I love you...all is groooovy.

The concept of white and black clouds, well, it's not official until I've actually been the responsible one on call. We'll see yet what my true colors are. Perhaps fate, just like attendings, doesn't really care too much what medical students say. Here's to being productive.

Transition, Part 2

Seriously, am I that full of myself? Oh well. I guess I really do have what it takes to be an MD.


"He saw: this water ran and ran, incessantly it ran, and was nevertheless always there, was always at all times the same and yet new in every moment..." --Siddhartha, Hermann HesseTransition. The day is fast approaching when there will be new initials after my name, when responsibilty for patients is real. And yet that day will be no different than any other day in the particulars. It holds some special significance, but more in the awareness of the destination rather than the steps taken. Haven't I been studying to become a doctor for four years? And will I somehow become a doctor when I start as an intern? Yes, and no. The path is what matters, but the transition points are the source of anxiety.

I have a trick for this. I put myself on the other side in my head, and imagine myself at the end of intern year, a bit more jaded but also more confident, efficient, and still open to learning. Developing my own ideas. The white coat is longer. It is no longer difficult to write a script from lack of practice. Calling in a consult is only occasionally terrifying rather than often or always.

That is the nature of our transitions. We are always who we are and yet always renewing; tomorrow I will be who I am now but I will also be new and what I did today will be gone, yet it will have decided who I am.

The picture above is of the Rio Grande. The river south is flat and placid, often shallow to the point of disappearing, but higher, in the narrow canyons by Taos, it is a deep and raging thing. It is the same river in both places.

Me, MD.



The final week of my 3rd year, I scrubbed in on a hysterectomy for a 500 pound woman. I commented before the case that I had also seen her every morning for my entire internal medicine rotation, prompting my attending to comment to the patient, in the OR, that 'you're almost like a bookend' for my first year of clinical training.

Morbidly obese patients seem to make fantastic bookends. This final month of my clinical 4th year, that same woman is in the ICU with sepsis. Again. And, we had another patient admitted who was over 500 pounds, because he had fallen three times in the last week, and couldn't get up each time. His chief complaint was knee pain. Hmmmm.

As this article in the NY Times illustrates, fire departments and EMS providers around the country are buying 'bariatric' stretchers and 'bariatric' ambulances. Picture here courtesy Stryker on the NY Times website, so I may have to take it down.

Our attending commented that he doesn't think that this type of obesity is common, and that the obesity epidemic is more comprised of the just-barely-obese; I beg to differ. I've seen more morbidly obese patients than I have pancreatitis patients, or hepatitis patients, or AIDS patients (even in Milwaukee), or colon cancer patients.

When I say morbidly obese, it does get, well, morbid. As in, 'suggesting the horror of death and decay', here. It's hard to describe the reaction to someone of this size when they are sick. In my experiences, these patients could not perform any routine hygeine, and were sometimes incontinent not due to any urinary defect but due to an inability to reach the bathroom. One woman died of urosepsis from an indwelling catheter she used for this problem. She died because she couldn't get up and go to the bathroom. Their skin folds were so deep and extensive that they would become infected with yeast, which would allow the entry of bacteria, which often led to sepsis via panniculitis, or infection of the panus, the word for overlying fat rolls. They often had chronic ulcers, which again led to sepsis. And when they were intubated they couldn't breathe because the fat was too heavy for the lungs to expand properly.

The woman above, when she started to recover, didn't want to leave. She was the first patient where I was taught the trick of pushing down on someone's abdomen while listening, thereby hiding the fact that you were testing for pain. I pushed down the stethoscope; nothing. I pushed with my hands; Oh God, terrible pain, 10/10, doc, I can't stand it. I assume that the hospital nursing care was superior to the in-home care she had to receive.

Mountains of illness, geological formations of pestilence, people encased in double or triple the amount of pure protoplasm they should have, decay, stench. I don't describe this to be judgemental; obviously, these patients had reached an apex of obesity beyond that of the occasional trip to McDonald's and a failure to eat enough leafy greens. Everything was more difficult. Rolling them in the OR took five people instead of three. They didn't fit on the gurneys. The instruments weren't long enough. Their tissue died more easily because fat is poorly vascularized. And so on.

An epidemic, indeed. Bookends of illness against which I often feel helpless at the sheer enormity of it all.


The Laying On of Hands

Today at conference we ended up going around the table and swapping stories like geezers comparing fish. Here, in no particular order, are some of my favorites.

Elderly, gaunt gentleman with a giant sternal scar from a CABG comes in with nausea, vomiting, and a mass pushing up like a grapefruit just below the lower edge of his sternum. I walked in and started to ask questions, nonchalantly examining his abdomen at the same time. He was going along while I noticed a large hernia, probably at the base of his old CABG incision, and gently applied steady pressure for twenty or thirty seconds. Pop! In it went, and his lump was gone. "Cured", I said. He stayed for a couple hours for observation and went home. Priceless.

An elderly granny, cute like only old people are cute, took her morning beta-blocker and promptly 'bradied down' into the thirties, starting to get loopy as her heart rate dropped. We came over to see her, and my intern, having just pimped me on the antidote to beta-blockers--glucagon--proceeded to fix her with one dose. Way, way cooler than atropine. From an intern. Big shoes to fill, big shoes.

One man, having a full-on, strength-sapping, one-sided-weakness-causing, speech-slurring, tragic stroke, sneezed. And was cured. No joke.

Scruffy, unshaven construction worker comes from the bar, not for trauma, or a fist laceration from someone else's tooth, or alcohol poisoning, but for supraventicular tachycardia, narrow peaks of anxiety ticking along regular as clockwork at about 160 or 180 sitting in bed. Joe, the attending from Chicago who's seen everything and works nights as if he's of the undead, walks in, nonchalantly. We prepare the adenosine, get a line. Joe says, head cocked to the side, "try something for me...bear down like you're going to the bathroom." So the scruffy guy valsalvas hard, and beep...beep...right down to about 75 or 80, normal sinus rhythm. He sticks there, too. Beautiful. About 1 in 4 SVT rhythms will break with a valsalva maneuver. Free, easy, all-natural, organic medicine.

Here's to the fun cases.