Tuesday, June 27, 2006

coulda been cool

The thing people tend not to get about Emergency Medicine is this: it's not about diagnosing what's wrong. I mean, yeah, 99.9% of the time, our people can tell what's up, they can find the problem behind the problem, and they have a plan that will in fact fix it. But when it comes down to it, that's actually what primary care is about. The ER is not supposed to be a source of primary care, and it will never be an optimal one. We're... well, it's a big issue, but suffice to say, we're not about that. Emergency is instead about finding out what is not causing someone's symptoms.

Headache? Hmm. Could be a simple tension headache. Or maybe a sinus headache. Or maybe, a DEADLY BRAIN TUMOR. Go to your friendly local clinic, and they'll be sensible about what it probably is. They'll test you for the most likely causes, and if it turns out it's not one of those , they'll start busting out the more expensive tests, looking for the weirder things. This approach catches more things sooner, and wastes as little resources as possible. Almost all the time.

Meanwhile, in the ED, our list of potential causes -- our differential diagnosis -- starts with the scary shit, and works downward from there. It treats time as the king-daddy most important resource, which is absolutely true, in the most emergent cases. Chest pain, shortness of breath, dizziness: not uncommon things, and probably not serious. Except when they're really serious.

This, by the way, is why so many things seem to take so long in the emergency department: if it can wait, it will, because there's probably something else going on that really shouldn't wait.

So for that headache, we knock the deadly tumor off the list first. We can check off stroke or other hemmorhage soon after, if not with the same test. And soon, we know what the headache is not. We may or may not yet know what it is, and that's the point. Honestly, at a certain point it ceases to be important, within the realm of emergency care. It becomes the kind of headache that the emergency room is simply not well-equipped to handle.

Anyway, long story short, when a resident said to me recently, "I have no idea what's causing her symptoms," that was not a bad thing. In fact, since he could say exactly why it wasn't malaria, or encephalitis, or any of a number of other things on the list, it was probably good news.

My shift ended before I got to hear the end of the story, so I can't pass it along. I just know it's not malaria. Which of course is good, because nobody needs malaria (and too many people have it). It would have been a neat thing to be able to say, though.

Monday, June 26, 2006

blog niblets, historical edition

Okay, because it's been a few days since I've posted, because I want to keep up the flow of ideas, because I'm always talking about how I'm going to get around to telling some cool ER stories, and finally because I'm always obsessing about how to do that while also respecting confidentiality, here's what we're going to do today: I now present to you a list of very short-but-true little factoids. The following things happened to me at some point within the past three years or so, although the non-clinical stuff goes back farther. Note: the few identifiying details that might be present are subject to change, so you'd never figure out who, when, or where, don't even try.

* The first time I set foot in an emergency department as a patient, I very nearly, as my British friends say, pulled. I struck up a pleasant conversation in the waiting room with someone who I think was there with her friend. My swollen glands and constant pain were not enough to keep me from turning on the charm.

This was an early experience that cemented two ideas for me: one, I'm even more charming and attractive when I'm in the healthcare environment (which is weird, because way back then I was only an erstwhile transcriptionist, and was still in deep denial about the idea that I'd ever want to practice medicine myself). Two, upon thinking about it, something about hitting on chicks in a hospital, or having chicks hit on you in a hospital, is just plain weird. The professional detatchment thing would later turn out to be easy for me, and maybe this is part of why.

It would be a cooler story if I got those digits, though... it woulda been nice to have a better self-image back then. And besides, my strep was gone in like a week.

* The first time I set foot in an emergency department as a student, I observed an attempted suicide case. The patient would turn out okay medically. The note was sitting out on the countertop. I don't remember it word-for-word, but I remember how it felt to read, and how clear the writing was. Here's where I learned about the reverent, church-like feeling of being witness to the extremes of human experience; how people's bodies and the artifacts of their lives are laid out for view.

Now that one of my job responsibilities is gathering and packaging trauma patients' clothing and personal belonings, it's hard not to think of this clinical, dispassionate view in chaotic, passionate times. We take care of that stuff, man. We document piles of clothing and the contents of pockets like archival materials, and handle them like just-purchased Christmas presents.

The one time I, in my capacity as a lowly tech, walked upstairs to sit in the surgery waiting room and talk to the family of an accident victim was to explain to them that their family member's clothing had been so thoroughly cut by our shears, and was so saturated with his blood, that I felt they would agree it was better to throw it away. Red-eyed and waiting for news from the OR, they considered what it would have been like to open a brown paper bag and see their loved one's stuff like that, and told me thanks for thinking of it, of them, in that way. I'm glad I was right in this case, because the hospital's rule is right, in general: that decision was just plain not mine. If it had turned out they'd wanted the shredded, soggy stuff, I would have gone searching in medical waste.

* I'm pretty good at reading X-rays, although I need to get over this thing where I spend significant time looking at the wrong part of the picture entirely.

* I've been offered the opportunity to do all manner of things with needles and blades that I probably shouldn't do quite yet. I've turned those down, but I do know how to put a dislocated finger back in place.

* I was an EMT for just shy of three years, and I carry a bag in my car with splints, bandages, scissors, and basic things. I stopped by the side of the road as the first responder to an accident, last winter, while I was out east. I didn't use anything from the bag except a pair of purple gloves, but speaking as a guy with a four-year acting degree behind me, I'll tell you what: those gloves, plus the shoulder strap of the bag slung across your chest? The knowing what to say, and what to do? That shit is theater. Pure and simple. And it helps people. All I had to do was talk, really, until the volunteer rescue squad came. Those guys were basically me, plus of course years of experience, plus a big truck with all the necessariy equipment and cool lights.

But the theater is the most important part of the equation.

Wednesday, June 21, 2006

I agreed to what, now?

I can't say I've figured out my work schedule, but I did talk through it, and write out a little calendar-slash-chart thing to give myself a visual.


3pm to 11pm tomorrow (well, today I guess), and the same again Thursday. Cool; I can check out a bunch of apartments tomorrow (well, today I guess) before work. Friday I have off; that's sweet. And then Saturday it's 11pm to 7am (wait -- is that Friday night at 11pm to 7am Saturday, or is it the last hour of Saturday into Sunday, and then the last hour of Sunday into Monday?).

Then I start the actual pattern at the beginning, and the first Sunday of the pay period I always have off (except for the 7 hours of Sunday I work because I started a shift at 11pm on Saturday, of course). The middle of the week varies a little, because I'm only guaranteed eight shifts in a two-week period, and they could be evenings (3 to 11) or nights (11 to 7).


I guess it's good that I'm a night owl. Unless it's really, really bad. And also, which box has my scrubs in it? Oh crap. Gotta go find those.

Friday, June 16, 2006

Too Legit to Quit

Happy news today; I'm being upgraded to just lazy and homeless, as opposed to being Teslagrl's lazy, homeless, unemployed boyfriend. I stopped by the hospital on a recent morning, to attend the weekly emergency dept. conference thingy. I drank the coffee, I ate the bagel and cream cheese. I saw some people I hadn't seen in a while.

Something about me (or them, or the spot we presently occupy in the yearly schedule) must have changed, because when I went home over winter break, people were like, "oh. You've been gone?" Whereas today, I got handshakes and friendly greetings from various staff, faculty, RNs, and residents. Maybe it's because during the last year, I may have doubled or tripled my actual knowledge base, and now radiate a sense of reduced dumb-assedness. Maybe.

In any case, I sat through the third-year residents' presentations of their "scholarly" work; some of said work was really good, and either will be or has recently been published in medical journals. Some was... well, let's just say that anyone in my Micro tutorial could have PowerPointed circles around a couple of these folks. Have no fear, sick and injured of the Twin Cities. They're good doctors, and their presenting skills are unimportant; it's just that they happen to be not-so-stellar in this case. My take-home message was, "dang, I guess all that stuff I did at that weirdo college will pay off in more ways than I know about."

And I tracked down my boss, a very busy guy who tends not to return a phone call unless he has an answer to the question being asked. Which is difficult for me, since I spent all that time in the world of "gosh, sir, we still haven't located that document, so if you'd like to send it again, you should feel free, or if you'd prefer I can just check in with you on Friday and let you know where we stand."

In this case at least, the suspenseful way isn't too bad, because we went pretty rapidly from "so hey, what do you have for open patterns?" to "it's about the same pay as part-time, maybe a little more; you'll be earning benefits; and orientation is on Monday." The only potential kink is that I'll be working shifts that are either 3pm -11pm, or else 11pm - 7am.

Still, I can work my other daily activities and socializing around the hours, and indeed I'll need to hone this skill if I'm going to work in Emergency Med the rest of my life. Plus I've learned to live on not very much sleep. Plus my sense of what time of day is appropriate for working has been completely scrambled by Bennington anyhow.

And speaking of 'scrambled,' there will be days when I get off work at 7:30am, and go directly to the little diner a block from the hospital. Sleep til 2pm, study GRE stuff. If it's a work night I take a nap. If not, I go out. Could be worse.

Monday, June 12, 2006

Today's Flash of Brilliance

Not mine, unfortunately. I'm still working on taking a nap. However:


...is sorta a podcast and sorta a calendar. You tell Podbop what city you live in, and it spits out a bunch of bands that are coming soon to venues near you. Hey presto, you've got MP3 songs to download and listen to.

Well, you do, if you live someplace cool like Minneapolis, where Podbop can find info listed and people have made music files available. I entered a couple cities where potential med/ grad/ PA schools are, and results are spotty. People in ABQ: get on this!

say shhhh

Hey. Welcome to curious onlookers from Jon's blog. He's a pip, even if he does eff up my (admittedly pretty lackadaisical) campaign in the general direction of anonymity. Still, it's not an uncommon first name, and anyway I've always figured that a med school admissions person who was sufficiently curious (not to mention motivated, tenacious and obviously very intelligent) would find this place. Truth be told, I actually sort of like the idea of letting the stuff I came up with during my regular ol' life speak for me, during the high-stakes period when I'm being evaluated for entry to my career. Naturally, the context is totally different; this is both more and less than some "additional information" page or appendix to my application. And maybe I'm naive or just a gambler, but I gotta believe the people in charge would know and appreciate the difference.

Anyway, if you're new -- what I do here is try to track my progression from the rakish and charming liberal-arts guy I used to be to the steely-eyed, unflappable medical professional I'm turning into. It's a weird process to watch your friends go through, and it's even more bizarre to be in the middle of it. There are plenty of "med-blogs" out there -- I intend to link to more than I already do -- and I like to think that eventually, this will be... one of them.

So, hey, now that my whole post-bacc year is over, I can probably tell some stories. But first, the obligatory statement about how I do this.

I make sure I'm respecting confidentiality in a few different ways at once, because I'm more than a little anal about it. Not only do I alter identifying details when I talk about situations, I also wait until it's no longer possible to figure out who was who by looking at the order or the timing of the events. Maybe that's too much caution, but in the age of Internet vs. HIPAA, I'm not sure there is such a thing.

Right now, I need to take a nap. For like three days. It was an intense year. But I'll write soon enough about the "you should stop smoking" speech and other Urgent Care gems; the time we called 911 from a party at our house; the time I stopped at an accident scene; and various other really nerdy stuff that comes from a Minneapolis kid going to school in small-town Vermont.

Tuesday, June 06, 2006

hey, well, that was a year right there, that was

Hm. How about that. I survived. The year is done.

I have, right now in front of me, my post-baccalaureate certificate. As promised, it is indeed suitable for framing (although what kind of hippie alterna-college prints diplomas portrait-style?) It looks just like the diplomas the seniors got. I know this, because during my year here I went a little native, and got to be friends with quite a few seniors. I'm also coming home with my worldly belongings in my car, just as I did on the way out, except this time there will be the addition of what I would estimate to be thousands of dollars' worth of art... which cost me $27 total.

It's a sad time, as we look back, as we do various things for "the last time." As we say goodbye to people. But it's also exciting, because having survived this crucible, there's a sense that we can get on with the larger plan, and pretty much rock it like a hurricane. I have a grad school to check out tomorrow, in fact. It's something like four hours away but it'll be a simple little New England day trip. Then I'll go home and pack. Then, I'll start the 22-hour drive back to the Midwest, back to my regular life, already in progress.

So, before we go, here are a few landmarks. Some little episodic things that are worth a nod now, in the post-game wrap-up.

In the Category of Always:

* I learned that I always do better if I take the time to analyze not only the question being asked, but how it's being asked.

A wise man told me, in my very first term here, that the key to academic success is to "fill in the fuckin' blank." Which is to say, be sure you know what "they" are looking for, because "they" may not recognize your possibly-correct-but-differently-slanted answer, and they certainly don't owe you any leeway. Be sure that the things you know come out looking and sounding like things you know. (This has been perhaps the hardest skill for me to develop, but I figure that's fair because it's also the most important.)

* I always think more clearly and do better academically if I specifically take the time to socialize.

Yes, at times that has meant driving home at 5AM. Or passing out in a dorm room. But one of my professors echoed a lesson I learned in the corporate world: if you're a natural procrastinator, or you have a short attention span, scheduling your work is going to be extremely difficult, and you'll wind up with a lot of work yet to do. What you do is to schedule your play; that way, you let the work assume that flexible, shapeless pattern where it falls into the many cracks in between blocks of fun, rather than the reverse. You see?

I have this amazing new ability to go to bed at 2 (or 3, or 5) and then get up a mere 4 to 5 hours later, feeling refreshed. It's a little weird. Also in that vein, on those fun nights,
it's not a bad idea to drink half a liter of Gatorade before bed, and down the other half upon getting up.

* I was always grateful for the chance to have this experience. I live in a ridiculously beautiful setting, and although maybe I'm dragging my feet to go home a little, I know teslagrl understands.

Even when it was stressful, or stupidly stressful, or just so absurdly stressful that it had to be some sick existential joke, I was very aware of how lucky I am to be, if not so blessed by natural skill and brains as to say "able," at least sufficiently self-aware and tenacious as to be "willing" to come out here and do this. I'm livin' the dream, for reals.

The only other thing that cost me $40,000 that was this rewarding was my divorce. (Zinnng!)

* I always kept the hot tub clean and the pH balanced. If I learned nothing else about chemistry (and the Prof might very well believe that to be true), I learned how to do that. I even got a special award at our year-end picnic for it. Heh.

In the Category of Never

* The passing out in a dorm room thing only happened once, actually. I was never quite as much fun as I claimed to be. But that's better for all involved, really.

* I never felt old. I was the oldest student in the school not pursuing a "real" master's, I think. And I was older than at least two faculty members.

Oh, sure, once or twice I was mistaken for random campus-crashing outsiders. Or faculty. But on the whole, "the kids" were accepting and very cool. And when I found the black-wearing, #27-smoking arts crowd, I was once more among my true people. It was like undergrad, except now I was working on science, which turns out to be as meaningful and yet impenetrable as my grad student friends thought their radical theater of the 1930's stuff was. Turnabout is pretty sweet.

I just had a birthday, so now I feel old.

* I never once spoke seriously about giving up. I'm not sure if I ever joked about it, except for being mock-excited about podiatry ("the career of the future"). And I still tell the Drummer I'll come visit him when he's in school in the Caymans.

Regrets? I've had a few. But then again, too few to mention. More later, maybe from the road.