archives


I have finally finished transferring my archives from the old homeschooledmedstudent site to here, since that one is going off-line. I’m not too pleased with a lot of what I wrote back in medical school, especially second year; but I figure I ought to save it, just to see how things change over time. I was crazy about politics back then, and it’s a little embarassing to see how much I cared about different politicians, who turn out to be nothing but broken straws. This election will be much less stressful to me, since I have no time to pay attention to it.

On the other hand, I used to be bolder and more open about ethical and religious discussions, both with colleagues and with patients, than I am now. I’m not happy that I’ve gotten so wrapped up in the mechanics of residency that I don’t have energy for that anymore. March 2005 I was very much into the Terri Schiavo case; and I’m still trying to decide how much my opinions have been changed by having more experience with ICU patients and brain-damaged patients. I still think she was murdered, but I’m not as sure of the practical applications to my patients.

It’s also funny to see how set I was on ob/gyn all the way through school, and what an about-face I did at the end of third year. It serves me right for giving smart-aleck answers to everyone who warned me about setting my course too far ahead.

It must be something in the air. That, or reading my sister’s holiday supply of Calvin and Hobbes comics. I’m feeling particularly silly and hysterical. All five children at home for three days in a row is really beginning to add up to some very interesting interactions. I forgot what fun it was to insult my brother. . .

The pile of gifts under the tree is getting tantalizing. I can’t remember which all gifts I wrapped. Can we just open them now? I keep trying to make a stack of books to take on the skiing trip, but half of the ones I’m planning on are wrapped up under the tree for someone else.

Monday morning we’re leaving early to go skiing for five days in New York. I’m not really sure why we planned a route that necessitates going through Buffalo, which as I remember always has a blizzard right after Christmas; but oh well. We should get back two days before the next schedule starts, so that leaves time for getting stuck in the snow.

On a more serious note, here are two excerpts from John Donne’s La Coronna:

ANNUNCIATION

Salvation to all that will is nigh;

That All, which always is all everywhere,

Which cannot sin, and yet all sins must bear,

Which cannot die, yet cannot choose but die,

Lo ! faithful Virgin, yields Himself to lie

In prison, in thy womb; and though He there

Can take no sin, nor thou give, yet He’ll wear,

Taken from thence, flesh, which death’s force may try.

 Ere by the spheres time was created thou

Wast in His mind, who is thy Son, and Brother;

Whom thou conceivest, conceived; yea, thou art now

Thy Maker’s maker, and thy Father’s mother,

Thou hast light in dark, and shutt’st in little room

Immensity, cloister’d in thy dear womb.

NATIVITY

Immensity, cloister’d in thy dear womb,

Now leaves His well-beloved imprisonment.

There he hath made himself to his intent

Weak enough, now into our world to come.

But O! for thee, for Him, hath th’ inn no room?

Yet lay Him in this stall, and from th’ orient,

Stars, and wise men will travel to prevent

The effects of Herod’s jealous general doom.

See’st thou, my soul, with thy faith’s eye, how He

Which fills all place, yet none holds Him, doth lie?

Was not His pity towards thee wondrous high,

That would have need to be pitied by thee?

Kiss Him, and with Him into Egypt go,

With His kind mother, who partakes thy woe.

Certain members of the household are having college finals, and for some reason this entitles them to a monopoly on the computer. . . So I haven’t been able to get a webpage in edgewise for a couple days.

Last night I went to the ER again; since it was freezing rain all evening, this probably came under the category of “idiotic medical student.” (I had received a speech on that subject by my preceptor, who with many smiles and no apparent thought of immediate application made many remarks on that idiotic things that he had known medical students to do while he was a resident or an attending. I couldn’t really object, since I detected an uncomfortable similarity between those students’ thought processes and my own. I was in fact glad to listen, in the hopes of at least knowing what the attending will be thinking of me when I inevitably do the same thing. Usually it consisted of being too officious.) My favorite ER doctor had moved to the urgent care side, which is of course for the cases which are not urgent. Anything which develops enough even to need blood drawn is hastily sent across to the “real” ER. Mostly we saw back pain and whiplash, and some musculoskeletal issues for which people wanted xrays which their family doctors hadn’t wanted to do. There was one finger laceration, which she offered me to sew up, but I hastily recused myself. I have practiced a couple of times on pigs, always very clumsily, and I wasn’t about to start on a finger! We also went across to check on the big case of the evening on the other side, a young pregnant woman whose car had spun around and rolled over. When she came in she was semiconscious and covered with blood, thus very concerning. After she was washed up and sewed up and xrayed, it appeared that she wasn’t seriously injured at all. We got out the ultrasound and looked at the baby with her and her family for a while. I found the heart and the hands, and was so tickled to see the heart beat that I was ready to stop there, so the doctor had to take over and move the wand around to find a nice view of the face.

My ongoing fascination with Celtic music: I’m frustrated because I can get hardly any CDs from the libraries, and I’m not quite crazy enough to spend dozens of dollars on CDs from all the different groups I’m finding out about just to see what they sound like. Instead of Christmas carols, I’ve got the words to “The Foggy Dew” running through my head. I’ve heard three renditions, and I really like the Clancy Brothers best. “Right proudly high over Dublin town/ they hung out a flag of war. . . While Britannia’s sons with their long-range guns/ sailed in through the foggy dew. . . ‘Twas England bade our wild geese go/ that small nations might be free. . . ” But the catching part is the lilting melody, the way the tune catches up and down. You really have to listen to it.

That song has to do with an armed insurrection that some Irishmen staged during WWI because an Irish regiment was sent by the British to fight with bad planning/bad backup, and obviously got massacred. Thus the line “better to die ‘neath an Irish sky/ than at Souvla or Sud-el-bar.” I’m thinking about the implications of that. Is it really better to make a dramatic and attention-getting stand for your own minority group’s rights, at the expense of a larger war? But the Irish really had no reason to feel loyal to Britain’s goals in WWI; how could they care about the freedom of Balkan nations when they [thought they] had none of their own? I really need to read more about Irish history, so that I don’t just go subscribing to their romantic version of the story.

I know people have been parsing this election up and down, trying to explain what happened, from both sides of the aisle. This is a debate explanation: In any public policy discussion, there is an affirmative and a negative side. The affirmative proposes a plan to fix problems in the status quo. The negative defends the current state of affair, saying things aren’t so bad, and there’s a way to fix them that’s less drastic than the affirmative plan. The catch is that many debaters on affirmative want to spend their whole time talking about the problems in the status quo, and don’t give enough energy to making a plan and defending it. I learned from my coaches that if the affirmative team doesn’t make a good case for changing the status quo, and the negative does a halfway reasonable job of defending themselves, the negative team should win.

That’s what happened on Tuesday. Kerry and Edwards were the affirmative team, pointing out problems in the status quo, and proposing themselves as the solution. They lost, because they concentrated too much on the harms, and didn’t persuade people that their plan would really make things any better. The negative team, Bush-Cheney, did a good job of saying things aren’t so bad, and if you stick with us we’ll keep improving them. You can’t win a challenge to the status quo by only criticizing problems – you’ve got to have a good solution, too.

That said, must get back to studying. Halfway through blood, and a ton of leukemias to memorize. Plus, I have to review biochem for a tutoring session this evening. And, yesterday the dean talked to us about Step 1, and succeeded in scaring us all thoroughly. Which was quite necessary. I came home and made out a study schedule from now till June – at least, I started a schedule. :) And it calls for me to spend at least half of Saturdays reviewing old material. Which means I need to get a lot more efficient at learning new material. . .

Arrived this morning to discover that our sister team was hit with 15 patients overnight; so we insisted on picking some of them up, including one who was a “bounceback” to our team (meaning we discharged him within the past few weeks, and he came back with the same problem). This man lives in a nursing home, has severe dementia, but now his caretakers say he has “altered mental status” because he no longer talks to them. And he has a UTI. There’s no way we’re ever going to get him back to his baseline. . .

As I was walking down the hallway, I noticed our psychotic friend’s name on one of the rooms. I thought, huh, I supposed the nurses disliked him enough they would have taken his name down by now. So I poked my head in, and there he is, asleep on the bed. <aaahhhh!!> Just barely managed not to slam the office door behind me. He came back yesterday evening, and the on-call team very wisely refused to readmit him. So the “non-teaching service,” elderly doctors who are thoroughly despised by the residents for their sloppiness, took him, at the insistence of the chief of staff. He had a fight with another patient overnight. Psychiatry is now telling my resident that they’re not sure he doesn’t have suicidal or homicidal ideations, so they’re refusing to sign a note to that effect. They’re also refusing to pinkslip him to their own unit. I looked at the other doctor’s admitting note for him. It says something like: “Pt. is very pleasant, social behavior is appropriate. . . . Will consult psychiatry to rule out depression.” This on top of all the nursing notes quoting his wildly depressed, suicidal, and psychotic statements. So I wish the doctor and patient joy of each other.

The resident is of course disgusted, and promising to create a major scene with the chief of staff for endangering medical staff if the patient sets foot in our office. Of course, since he’s obsessed with us three, and me especially, I’m sure he’ll be in here as soon as he wakes up from all the ativan.

We arrived this morning to find that our friend the psychotic alcoholic had not left yesterday afternoon, but had disappeared in the wee hours of the morning. Also it appears that the police of another town in the state have a warrant out for him, so all the VA computers flash warnings to anyone who looks at his chart: “notify police as soon as this patient is discharged.” Well, he wasn’t discharged, so who knows if the police will find him. He shut the door on himself and my resident at one point. She was terrified, but thankfully before the situation progressed the intern around the corner walked in and ordered the guy out. Even professional women appreciate chivalry at times like these. Later on the patient threw a phone at a nurse, so now all the nurses scowl and point in the opposite direction if I try to ask questions about him.

So the status now is that he’s gone, and psych hasn’t written a note to say they told us he was competent and non-suicidal, non-homicidal. Which leaves the main documentation as my note saying that he is psychotic, suicidal, and homicidal. And I don’t care what that psychiatrist said, if the person can’t even stand to listen to you ask him to sign out AMA (against medical advice), he is not in his right mind. I am left with the thin hope that I can’t get in trouble for noticing a fact that I was powerless to do anything about.

On a more cheerful note: this morning the attending, a hematologist-oncologist, took us around to his lab again, and it was once more my turn to look at the slide and assist in discussion. The subject was autoimmune hemolytic anemia, complicated by MI in a young person for lack of oxygen-carrying cells. The trick is that you should transfuse the patient in spite of all the compatibility tests being wrong, because in this case there will be no dramatic cell lysis, just the spleen slowly tearing the cells up.

Then, as everyone was walking out, the attending announced, “I want Alice to stay.” So I sank down on the chair. End of the month, time for evaluations, but why just me, not the other student? He asked what I want to do when I grow up, and I said I’m planning on OB/GYN. He pointed out that I hadn’t done that rotation yet, and then began saying I’m very knowledgeable, and would make a great internist, and in fact a great subspecialist, and he would love to write a letter of recommendation for me. I was flabbergasted. Two quiz sessions where I stumbled on the right answers (and he’s overlooking my very lame performance in rounds the last few days), and he’s inviting me to do heme/onc, and offering letters of recommendation?

If there’s anything I don’t want to do, besides radiology, it’s heme/onc; but you can’t possibly say that to such a compliment. So I stammered that I’m enjoying internal medicine, and thank you very much, and staggered out. But what a lovely confidence-booster. God, send that the ob/gyn attendings are this easy to impress!

The ER finally woke up and sent us two alcoholic patients: one for detox, the other with cirrhosis, ascites, and hepatic encephalopathy. (They also kindly neglected to draw labs on the encephalopathic patient, which leaves us flailing a bit helplessly, because it’s contrary to our modern reflexes to make decisions or prescriptions without lab numbers. Even though the guy is patently sick.)

His skin and eyes are yellow, and his hand are shaky. He started off whispering, I think in order to get me closer to him, but finally progressed to a hoarse croak in frustration at my lack of mind-reading skills.

—————

The blog and I are having, apparently, even more trouble understanding each other. There was a whole splendid description of how he kept trying to get closer and closer, and I kept trying to find the way back to the door, and how he bothered the resident too, but since this isn’t an official history I don’t have the motivation to type it up again.

The interesting part was when we decided he needed paracentesis (needle in peritoneal space to withdraw fluid) to relieve the ascites, and find out what the exact cause was, and if there was any infection. The resident generously agreed to let me do it. All the while we were setting up, he was trying to hold our hands, promising to be “very compliant,” but also insisting that we not hurt him at all. Then, when we actually got down to it, he became very jumpy and nervous, and the resident had to order him very firmly not to talk. That didn’t keep him from making a vast commotion when I was trying to inject the lidocaine; and between him squirming, and the resident over my shoulder insisting that I put it just under the skin, no deeper at first, it took me a couple of tries just to get that needle done. This, by the way, from an iv drug user. Then there was the big needle with the catheter, to withdraw fluid. I got it through the skin, and felt it punch through some kind of resistance, which I figured for the muscle wall, and didn’t dare push much farther. (Earlier in the day the resident had met the surgeon who had assisted in downward course of the patient who got a punctured colon when a different resident did paracentesis on him, and who ended up with peritonitis, emergency surgery, and death. So I was feeling gingery about getting the needle anywhere close to this guy’s intestines.)

The resident had to take over, and pretty soon hit the spot, and started withdrawing fluid. But the guy wiggled so, we weren’t able to get much, just enough for some basic tests, not enough to be really therapeutic. But I was satisfied. Not a completely successful procedure on my part, but on the other hand I didn’t injure the guy. I’ll settle for that for now.

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