Not exactly the hub of health and wellness makes Las Vegas a great place to practice Emergency Medicine. For those who actually still point and click this site sorry for the 1 yr delay, but I have been... uh, busy with match, then other rotations, then moving, then the actual set up post move and finally residency. As you can imagine, it has been busy. My first month was orientation followed by a couple of weeks in the ED. The second month was CCU which gave me a total of 4 days off and several 30 hr shifts. This month I am back in the ED and doing shift work, which is much nicer than living at the hospital for the month. Anyway, I will try again to drop some more info on this site to keep folks up to date. best regards, Troy

Well, I made the road trip and it was relatively uneventful aside from the stop in Bozeman to see Jesse, a stop in Sturgis to see have lunch with my brother, who decided to make the annual HD rally. What a specticle sturgis was! Girls in bikinis and riding chaps and millions of dollars worth of motocycles. I read that they expected 500,000 bikes to pass through in the coming week! Most impressive is that the town itself is the size of a postage stamp. And, finally a stop in Chicago to visit with my long time friend Rich. Anyway, I finally made Grand Blanc and have managed to survive my second day on an ortho rotation. Its a little unorganized here, but I think I will find a groove once the dust settles a bit.

Mrs. M is in her 70’s. She has led a good life and is in general good spirits despite her failing heart, the fluid on her lungs, and current low blood pressure. I have been taking care of her for the past week and find her to be cheery and pleasant. Her husband usually comes in around 9 with the paper and coffee and stays with her through the day. I sneak in to chat with them whenever I get a chance.

On this particular morning Mrs. M gets an uneasy look on her face when I ask if she has any questions. “Well yes,” She says “I don’t mean to be snotty about it, but I was wondering since I seem to be getting a lot of attention, and my husband and I don’t have a lot of money… is this all going to cost us more?”

Apparently she was feeling that she was getting an awful lot of attention during her stay at Providence and thought that she should clear it up in case there was some misunderstanding, because she really was on a fixed income and couldn’t afford such fancy attention.

I explained to her that this was one of the perks of being at a teaching hospital. Lots of young doctors in training like myself coming by to see how things are progressing. I assured her that her “extra” care was not at an “extra” cost and that as a medical student I am encouraged to sit and talk with my patients and learn from them as much as possible. “It is an important aspect of providing quality care that we get to know you,” I said. “and frankly, from my perspective it is the best part of the job. It is why I do what I do.” Anyway, we both chuckled a little bit and I excused myself to my morning report meeting hoping she didn't get charged extra.

I am sitting with coffee and my laptop scrolling through the NYTimes front page when I overhear a woman in her sixties say, “Well we didn’t drink very much of this last night, guess we should get busy before it goes flat.” I glance over my shoulder and sure enough she is pouring herself a glass of champagne. I laugh and ask what the occasion is. Apparently they had a party last night and hardly touched the bottle, so rather than let it go flat, after all it is bottle of Louis Valbray blah, blah, blah, it was decided that a 7AM drunk was in order. When offered a glass I of course could not refuse. I had a broken car and had just missed my flight home for the holiday, so what the hell. I wasn’t going to see my girl, wasn’t going to see my family, wasn’t going to ski, and in a few hours was going to shell out $600 + dollars to get my car back, so pour away!

The tow truck driver showed up during my second glass and I sent him off with the address of the mechanic. I went back in to the venu and proceeded to finish off a third glass, but by the time the fourth was poured my head was dizzy and I had gone from tipsy to nearly drunk. Drinking on an empty stomach at 7AM will make anyone but the most hardened professional into a cheap date. Patty the cheery grandmother gave me full custody after her second glass so I tucked what was left of the Louis blah, blah, blah under my arm and wandered back to the Murphy digs around 8:30 for some breakfast. Following breakfast, yup you guessed it, I took a nap!

At around 2PM the phone rang and the boys at the shop had my car ready. Tom had left his bike for me to ride, so I hopped on it. With mildly dragging brakes, no grips, and a nasty headwind filled with desert dust, I embarked on my 45 min. ride to the shop in flip-flops and a green polo shirt.

Easter Egg

Thursday following a half day of lecture and a post rotational exam for Family Medicine, I topped off the tank of my 91’ Subaru and headed out of Kingman for Phoenix. I was scheduled to catch a plane to Seattle the following morning so that I might join my family for Easter Sunday.

The drive from Kingman to Phoenix is risky because is it a major route to Vegas, and because it is only two lanes wide. Other than the high potential for car crashes it is a relatively boring three hours. This trip was accident free. The boring factor was increased slightly due to construction that caused back ups for about an hour. Nothing else rates quite as high on the boredom scale as being parked in your car on the freeway reading a book and waiting for traffic to move again.

I arrived in Scottsdale some time around 8PM and pulled through the gate of my friends condo. I pull into the parking spot and as if on cue my car begins to make a metal-on-metal noise that indicates in no uncertain terms that I will not be driving the car again until it gets fixed.

I am, of course, thankful and pissed at the same time. Pissed that my car just broke down and thankful that it waited until I was at my destination. The alternative of breaking down on the narrow road in between Kingman and Phoenix makes getting poked with a stick sound good. Pouting, I stomp up to Tom and Amanda’s digs to let it sink in.

I let a half hour pass and go back to investigate. With flashlights in hand Tom and I pop the hood. I am fully expecting something to be grossly distorted and dripping oil, but of course the engine looks normal. Great. We both peak closer and I see fresh metal shavings on the power-steering pump belt. A close inspection of the pump reveals more shavings. Tom starts the car while I hover over said pump to verify, yup that’s the culprit. The rest must wait until tomorrow.

Up at the ass crack of dawn I locate a couple of Subaru dealers in the valley. Next is the call to AAA to get the tow truck on its way. Once the clock has started with them I find and actually talk to a mechanic that can get the car in that day, so at 7 AM I find myself down at the clubhouse waiting for the tow truck to arrive…

Part of a doctor’s responsibility is to enter people’s lives and bodies. We are granted the right to do this by our patients who entrust their lives and health with our knowledge and skills. No place in my rotations has this been more glaring than OB/GYN.

In surgery we enter places not accessible to others, but this is done behind closed doors with patients under heavy anesthesia. OB/GYN draws a crowd. During the birthing process the patients, mother and fetus, are surrounded by family members. Husband holding the hand of his wife, mother applying a damp cloth to the forehead of her daughter, the best friend standing back with camera in hand. Into the middle of the action we enter and with gloved hand we are given carte blanche access to one of the most intimate places of the human body. Civilizations have been destroyed due to men’s coveting of this anatomical wonder, yet we, the healers are allowed, even expected to enter with the entire family looking on. It is a heavenly responsibility one that is guided as much by art as science. The modern shaman acting as a humble guide for these astral travelers, we reach into the dark infinite universe and ease life into the light.

To the uninitiated it may be a difficult threshold to cross, but talk to the mother and family during these interactions and it is clear there are really only two things on their collective minds... mother and baby safety. Rich, poor, young and old alike share this common concern and could really care less that the nurse, medical student, and physician are all taking turns throughout the hours to check the progress. They all wait and ask "How's everything going?" and they all breathe a small sigh of relief when we report that the stars of the show are tip-top.

I grow more confused everyday. This is not a trite comment about trying to learn medicine, but rather a problem of great import. Four months ago I was committed to Emergency Medicine. It was almost a given that this was the path for me, but after my first surgical rotation this all changed. I now find myself torn between several pathways all of which would provide me with a fulfilling practice.

Emergency Medicine: Pros – Shift work (read NO call), invigorating and exciting environment, being a generalist and specializing in resuscitation, no start up costs, good mix of procedures, short residency (3 years). Cons – No patient continuity, odd hours, high stress environment, little time with the patient.

Ortho Surgery: Pros – Get to work with my hands, better continuity of care, sweet tools and technology, high pay. Cons – Long hours, highly specialized, long residency (5 years), on call, super competitive residency programs.

Cardiology: Pros – Great mix of clinic and hospital time, ample procedures, good mix of pharmacologic, lifestyle and surgical interventions, good patient continuity, ample time to educate patients. Cons – Long residency (7 years), have to do Internal Med residency first, competitive fellowship, long work hours, on call.

This is an abridged list of Pros/Cons but you get the idea. Part of my problem also lies in the disconnect between my grades and my aptitudes. I could do Plastics or Optho, but I don’t stand a snowballs chance in Phoenix of landing one of those residency spots. My decision is also made difficult because I have legitimate economic considerations. My humanitarian sensibilities are in competition with my economic needs. The two are not necessarily compatible. On the one hand being a physician for the people and on the other being a physician for the people who can pay. Let’s face it, having student loans in excess of 200K churning at a 4% interest rate requires some frugal living even with a big paycheck.

Lots of personalities come together in the health care field. From patients and doctors to volunteers and administrators all walks of life are involved. This of course creates some interesting combinations. Sometimes these combinations mesh together in an almost seemless fashion, and other times the combinations are like oil and water.

I feel very fortunate to get to work with some of these people and personalities. Many of the individuals I look up to are the ones that have mastered the art of medicine which includes the ability to get along with all.

Case in point, today we consulted on a patient in the ED who was transferred from Whidbey Island. He had very typical chest pain on exertion and reported a couple of recent episodes of waking in the middle of the night with pain that stopped after he took his nitro. He is what we would consider a good cath lab candidate.

It was late in the day around 6 so Dr. S called up to the Cath Lab to see if the team was still around. He got off the phone, thought for a moment, then got back on the phone and told the person on the other end to send the team home for the evening. When he got off again he explained it to me like this.

“Our patient is stable. He needs a heart cath, but it doesn’t need to be done immediately. I feel comfortable tucking him in to the CV [Cardiovascular] unit, starting him on a Heparin drip and watching him overnight. The Cath lab team has been working hard all day and could probably use a break. My reason is partly based on the fact that Dr. B is slow and the team would be here an additional 3 hrs. If Dr. L were here I would do it now, because I know he is fast and it would only be an hour. If this guy gets into trouble in the middle of the night we can always call the team back, but for now I am willing to take the risk.” (I will save my balance metaphor for another post)

This is why everyone likes Dr. S. He knows how to allocate resources well, and his experience has given him the skills and knowledge to know when to jump and when to stand back and observe.

It doesn’t really dawn on you until you walk into the room and find that while the person in front of you speaks English they do so only minimally and understand even less. It is bad enough that even the most seasoned English speaking natives don’t understand half of what comes out of a doctors mouth, so to actually add an actual translational component really makes the job of providing quality health care to someone is nearly impossible. It makes me wonder how many things are missed simply as a function of poor communication.

Case in point, a woman presents to the cardiology office today for a follow up. She has a history of cardiac problems and can communicate this okay, but it becomes apparent that she really has no idea what I am talking about when I ask her if she is currently having chest pain and she says, “Yes, to the Uniwersity they took me.” Uh, right so I got some info, but not what I was hoping for so we take what we can get and move forward… “you mean you were taken to the University for chest pain?” “Yes.” Okay, now we are at least making some progress. This goes on for another few minutes, me asking questions and sifting through the responses to find direction. In the end Dr. S and I decide the best course of action is to schedule a treadmill test and an echo to assess the heart. At least this is a language we can understand and we don’t necessarily need to have a conversation to figure it out.

Of course another option, as told by one of my beloved mentors in the ED, is to simply “Carpet Bomb” them with enough labs and imaging studies that whatever it is will show up. Not very cost effective, but sometimes very useful.

We had a LOL of 81 yrs in yesterday that tripped on her dog and hit the floor. The end result was a broken hip that landed her in the ER. While broken bones happen to folks all the time without too much fan-fair, the meaning of a broken hip in an elderly woman spells disaster. The broken hip rapidly becomes a multi factorial problem that typically leads down a path of mental and physical degeneration. It is one of those things in life that is closely associated with the sort of decline that leads to death.

I always find myself wondering if the family realizes the gravity and potential meaning of these sort of injuries and my heart goes out to them knowing that this could possilbly be the beginning of the end for their beloved family member. Of course I am optimistic and offer words of encouragement and hope, but deep down there is a shadow of doubt.

My last patient of my surgical rotation was a woman in her mid 60’s. Nothing notably peculiar about her, she was presenting with possible small bowel obstruction (SBO) which ultimately resolved with a naso-gastric tube.

Before returning home for the evening I stopped into her room to chat with her and to see how she was fairing. After the formalities of “How’s your pain?” and “Have you passed any gas yet?” she asked if I might call her partner and her daughter to give them an update. I was glad to do it and scampered off to the nurses’ station to place the calls. Her partner, I’ll call Gordon, picked up the phone and said hello. I identified myself and apologized for calling so late, but that it was Ms. H who had requested the info be passed along. He was gracious and listened while I ran down the list of tests we had done and the info gleaned from them. I assured him everything was okay and encouraged him to get some rest. After prompting, he assured me he had no further questions.

At the end of the conversation he again asked my name and then added, “I just want you to know that I appreciate this call. I have had two separate families that I have been a part of both with their fair share of sickness and need for hospital care over my 74 years. That said I want you to know that this is the first time a doctor has called me at home to keep me informed, for that you get a gold star. Thank you very much. I think it is you who better get home and get some rest.”

I didn’t quite know what to say. I was flattered, but I was also a bit embarrassed that this was the first time he could ever remember a doctor calling him at home. I thanked him and apologized that my call was the first. I quietly hoped it would not be the last.

It made me reflect on how our profession has progressed over the decades from doctors making house calls to doctors barely interacting with the patient. It made me realize how important and powerful the doctor patient relationship can be and even how important and powerful the doctor-family relationship can be. It is a flame that I will do my very best to keep lit.

I got to place my first endotracheal last week. I totally forgot to post this exciting news. I was stoked! It is very interesting shoving a steel blade into someones mouth while they are not breathing and lifting in such a way to visualize the vocal cords and slipping a tube past them. The whole time you are kinda holding your breath too, because you know your patient isn't breathing and the closer you get to needing to take a breath the closer they get. Anyway, I was sweating it.

The process goes something like this: We give the patient something early on prior to coming into the OR to calm the nerves. Once inside there is flurry of prepwork that requires the patient moving onto the surgical table and getting strapped down. Once there they get an oxygen mask and the drugs are placed into the ready position (often Propofol and Succinylcholine). As these drugs are pushed in we monitor the eye lid reflex. When the patients eyes close we brush the eyelashes, if there is no reflex we give another breath, tape the eyes shut (keeps them from drying out and protects the cornea from a drape brushing them etc.). take the mask off, grab the blade in our left hand, scissor the jaw open with our right, slide the tongue blade into the mouth on the right and sweep to the midline, pull up slightly, hook the epiglottis and pull straight up taking care to not lever the blade and risk breaking teeth. Sometimes the right hand is, at this point, used to push down on the forehead to get a better angle and pull up again until you can see the vocal chords. Once these are visualized (it looks like a V in the throat) the right hand grabs the tube and carefully slides it in past the chords. A bulb is inflated to secure the airway and to minimize and leaking around the tube. The tube is attached to the breathing machine and silk tape is used to secure the tube externally. A piece of cotton is rolled up and placed between the teeth and we finish by checking for breath sounds and monitoring Oxygen saturation.

I didn't get the first patient I tried (not to worry, the anesthesiologist got it quick), but on the second patient I got it. I wanted to jump up and down I was so excited, but I kept my cool and simply told everyone I wanted to jump up and down. Somehow it was enough.

My patients are a good mix of high maintenance Histrionic types that play up the sick role for more attention and seriously sick folks that act like they are doing fine. My current favorite is Mr. W, he is in for an empyema of the lung (basically a big abscess). He recently had chemotherapy for his cancer so his immune system is trashed. We are trying hard to get him cleared up and back on track. One day this week he says to me "it doesn't matter how you start, what matters is how you finish." This was his response after I mentioned that I got a late start on my education.

Mr. W is the kind of patient that I could just sit and hang out and play cards with and listen to. Never bitches or complains just says, "You know you docs should really get outta here and get some rest." He is also a big college basketball fan and coaches a junior college team. He happens to know many of the great college hoops coaches. He told us a story today about how, when he was a kid growing up (In Indiana home of the Hoosiers I believe) he couldn't wait until he wore a size 7 shoe, because that meant he could get Converse All-Stars. Well one day in the gym he was lacing up a new pair and a grey haired gentleman came in and said "Son, if you don't mind I can show you how to lace those up so they are nice and tight." Well he obliged but didn't give it a second thought. Later he noticed that the same fellow was hanging around watching the practice, so he asked one of the coaches who the guy was. Of course you can guess the punch line "Oh, well, that's Chuck Converse."

I started to realize that people actually read this blog when people started to comment that I had not written in a while. In case you didn't already know I am on my first surgery rotation. The hours are long, but the time goes by quickly for me. I am in Sierra Vista, AZ (look it up on a map) it is SE of Tucson next to Ft. Huachuca Army Intellingence Base.

The doc is a military surgeon and splits his time between the hospital on post (base) and the community hospital. Between the two my day starts at 0530 and ends sometime around 2000 with some study time thrown in for good measure. We round on our patients in the community hospital first and last and in between we do surgery, see new referals and follow up on old ones. It is an enjoyable but long day.

Ever wonder why surgeons make lots of money? Because they work A LOT. I am pretty sure that if Family Docs put in the kind of hours surgeons do they too would be pulling down +250K

Anyway, I will try to post more often.

Today a fellow of 68 came in presenting with a cough that had persisited for a month and then some. He was troubled by the fact that he was no longer getting much sleep at night since it was alway worse when he would lie down. His SaO2 was 91% at rest and after two laps around the office it dropped to 88%. We gave him a breathing treatment to open him up a little and get his O2 saturation up and loosen some of his constricted airways. His cough was dry, but with the treatment he began to spit up some crud. I observed the first of this and was alarmed when I saw that it was very pink. Hemoptysis has a differential that includes among other potentially life threatening problems Pulmonary Embolism.

Well after discussing it with my preceptor we went back in and Dr. F began discussing the list of contenders for diagnosis. When he commented to Mr. W about his concern with the sputum Mr. W retorted, "blood, naw I just had a red Gatorade."

I think I would categorize this profession, especially for us students, as humbling right to the core. The lesson here? Never assume anything and always ask... even when you think you know the answer.

One of my friends, now a doctor, once said, "being a doctor is not who I am it is what I do, it is my job."  I thought about this comment for a nanosecond and retorted "Bullshit!" Now, before I explain why please understand I know what she was getting at, she doesn't want to be looked up to or treated differently simply because she is a physician. This I understand perfectly well. Our culture holds most physicians in very high regard simply based on their education. Sometimes this respect has simply not been earned, and I believe she was cautioning against this sort of cart blanche granted to physicians.

I, however, find that many of the doctors I encounter hide behind this excuse. For those that entered this profession with great idealism and hopes of saving the world my argument is this, anyone dedicated enough to spend a life helping others is changed by this process. You come in a medical student, but you leave a physician and it is who you are. For example, my neighbor stopped in a week ago. She had know idea I was a medical student, but she needed help. She was having a case of shingles but didn't know what was going on. All she knew for sure was that her neck hurt, she was dizzy and feverish and felt completely out of sorts. Up to this point she had only hid behind her blinds and yelled at us for temporarily parking our car outside the garage (ours not hers). Now she presented in need of help and it was my door she came to.

 Now I am as busy as the next guy with studying, work, domestic chores etc, but I dropped this and took her to the local urgent care so she could get the medications etc that I could not provide her. I would like to think that anyone of her neighbors would have done the same, but I saw it as my duty. I mean we could have simply called her a cab, but it seemed like a much better opportunity to get to know the individual from behind the curtain. I tell this story only as an anecdotal account of what I think it means to be a physician. Compassion does not stop when you leave the hospital and it most certainly does not stop when your neighbor, who has always been rude, needs help. Compassion is something that is a part of us as physicians, and if it is not it should be.

As for my friend who says it is just her job. She is simply trying to understate what she does to take our profession off the pedestal that so many want to place it on. If you talk to her you understand right away that she is passionate about what she does and absolutely loves her "job". As much as she and others like her want us to believe that being a physician is what they do and not who they are, I don't think anyone can go through this experience and not have it permeate your soul.

There is nothing quite like the feeling of being under the microscope. In medicine this is practically a way of life. For instance, today I got to do an SPE or Standardized Patient Exam. This is basically a role playing exercise that is monitored by actual doctors from behind a two way mirror. The set up is like this, we have one minute to review the chart in a folder on the door. After the first minute a tone sounds and a voice echoes "Student doctor, you are now allowed to enter the room and begin your patient exam. Once inside we have 15 minutes to do a focused history and physical. At the 13 minute mark the voice returns telling us all that we have two minutes, two minutes later it tells us to stop and begin the written SOAP note (read: Subjective, Objective, Assessement, Plan). We have 10 minutes for this task and at the end the doctor standing behind the glass the whole time comes into the room and tells us not only how we did but also what we did well and what we did poorly.

So for the first 15 minutes you sweat and alternate between thinking about this "patient's" problem, and which questions to ask, and how much time you have left, and what you are forgetting. The second ten minutes is spent writing was quickly as possible to get all the info down, only to find out that you have run out of room and are totally F'd because if your note runs out of the margins they won't grade it (Incidentally, this is one of the reasons doctors have such shitty handwriting. Seriously, try writing down a whole H&P in less than ten minutes and have it look legible... not an easy task). Finally, when you are discussing the whole thing with your proctor you realize that you forgot to put down two of the tests that you did during the exam that would have ruled out the thing your proctor is now telling you you should have done.

What I think is most amusing is how different styles play into to how we are graded. For instance if a doctor tends to approach their patients with chit-chat before the exam then they tell you, "You should try to open the conversation with something not medically related to relax the patient." Uh, okay, nice shoes. Or they will say, "You should never turn your back on the patient." Which is fine, but most will agree that you should wash your hands in front of the patient so they can see that you are being clean. The problem arises when the sink is on a wall and the patient is on the exam table, no matter what wall it is on you have to turn your back to the patient.

And so it goes with the hoops and such. We show up in our pressed white coats and ties, shake hands and generally smile to all that came before us knowing that someday we too can call our buddies and say "Doctor." All the sarcasm aside, the real microscope is going to come from within when our patients are in the hospital depending on us to ask the right questions and order the right tests. I just hope this training is enough.