it gets your blood pumping

Yesterday I gave the most blood products that I'd ever given for a single case. I kind of lost count, but I think it was on the order of 30 units of PRBCs, 30 units of FFP, 20 units of cryo, 18 units of platelets, not to mention 10 units of Cell saver, 6 bottles of albumin, and a smattering of other miscellaneous fluids. I had the rapid infuser going, and at points, I was putting up bags two or three at a time and actually squeezing them into the bucket to get the blood into the patient as fast as I could.

When I woke up this morning, my arms were really tired.

all important and shit




As of today, Joe has officially finished his residency, and is now an attending. He is living proof that the process of medical training dose not have to break you, or turn you cynical or bitter. He's a great doctor and I'm proud of him.

However, if he ever tries to lord it over me next year that he's an attending while I'm still a resident, I will kick him in the nads.

the walls have ears, and so do patients

Another rule of the OR: it is in very poor taste to talk smack about a patient right before a case. Especially if the patient is in the room with you. Especially if your anesthesiologist hasn't actually induced yet. (Or even after, really.)

Dude, she has a bowel obstruction, she ain't deaf.

* Medico-legal CYA clause: This entry is just a general observation about the culture sometimes observed in the OR. It is not about a specific case or a specific patient. *

save yourself from getting yelled at

Because it's almost July, this one's for the new third-year med students. A general rule of thumb for those not scrubbed in the OR: if it's blue, don't touch.

I have my fair share of contamination stories from when I was a med student. Probably the worst of which was early in my third year, when I was scrubbed into a urology case, and I forgot I was sterile and reached up to scratch my nose.

live free or die hard



Do you like stuff? Do you like seeing stuff get blown up? Then you know, you should go see "Die Hard 4". It is a movie starring Bruce Willis that does not involve talking babies. And also, the screenplay was written by Mark Bomback, who is the brother of my old med school friend Andy, a.k.a. "The Prankster" in The 12 Types of Med Students. (Joe was "The Sensitive Soul," by the way. Still is, that sappy jerk.) Even if you think the fact that the last thing the world needs is a fourth "Die Hard" movie, it is pretty fucking cool to be able to make it as a Hollywood screenwriter, or to find success doing any creative endeavor that you love. So...woo! "Die Hard 4"!

(Andy is actually an excellent writer himself--he wrote a personal essay last year that got published in the "Perspectives" section of the New England Journal of Medicine. The New England Journal! You should read it, it's good. In fact, that whole family is so talented it kind of makes me puke.)

thomas and "friends"



You know, I think I'd like this "Thomas the Tank Engine" show a lot more if he and his friends weren't such total assholes to each other. They're always calling each other names and sneering disdainfully at the other vehicle's appearance or speed or hygiene or what have you. And then at the end, they learn a lesson, but it's not always such a great lesson.

Like that one where the green train (Henry?) doesn't want to mess up his paint job so he refuses to come out of the tunnel. So then the fat controller (also--why do they always call him that? Mean.) gets so mad that he builds a freaking brick wall in front of the tunnel penning Henry in there FOREVER. (Or at least until the next episode.) "But I think he deserved it...don't you?" intones Ringo Starr. No Ringo, I don't think people should be INCARCERATED for not wanting to get wet.

Luckily, Cal doesn't really understand what they're talking about yet. The accents help too.

but no goo goos or twin bings




The hospital gift shop has the an extremely complete assortment of obscure candy brands. (They also have Bit-O-Honey full-sized bars, Boston Baked Beans, and all three flavors of Charlston Chews. I didn't even know that there were three flavors of Charlston Chews.)

a day in the life

As a follow-up to my post about how everyone in the hospital thinks everyone else is stupid (and whose small flurry of comments recreated the exact microcosm of stupid-calling that I was talking about, amusingly enough), I decided to tell you about how I spend an average day in the hospital as an anesthesia resident. I will just pick one day last week that I was on call, so you get the full 24 hour experience of it, but overall, it was a pretty typical day.

6:15am - I get to the hospital, go to the locker room, and change into my scrubs, my ugly orthotic shoes for old-lady back pain, and get my equipment bucket from my locker. I tie on my scrub cap and go downstairs to the OR where I'll be working for the day. I know I have two moderately large cases with the oral/maxillofacial surgeons, plus whatever other emergencies they float my way.

6:30am - Setting up my room. I am significantly less spazzy at this now, two years later, than I was back when I was a new CA-1. Basically, I think of administering anesthesia in the OR as running an ICU with just one patient, and as such, I want to make sure before the patient is in the room that everything is ready or at least available for an ICU level of care. I do my machine check, make sure my ventilator is working well with no circuit leaks and that my gas cannisters are full; check my backup O2 cannister in case there's some sort of oxygen pipeline explosion in the hospital and I need to use my reserves; set up all my standard monitoring; and draw up all my drugs and resucitation meds for the case. Knowing that I am going to be doing two midface reconstructions today, I run to the supply room to get a few extra things that I need that were not available in my room--in particular, a special tube that I know we will be using for the nasal intubation that I have planned. I notice that there is no arterial line setup in my room either (possibly purloined from my room last night for an emergency case), so I hurriedly make one up.

7:00am - I go out to the preop area and talk to my patient. We go through his medical history and then talk about the kind of anesthesia I'm planning to administer, along with the risks involved. Not that it's terribly risky, mind you, given a young healthy patient, but risk is never zero, and we talk about some of those issues. I pull aside the surgery team and ask them about their approach and my plan for intubation. The patient is also having some nasal surgery done at the same time as his midface reconstruction, but the surgeons tell me that their approach will be infralabial (through the mucosal surface of the upper lip) so my plan to nasally intubate will be fine. ("Are you sure they don't want to do it transvaginally?" my attending joked.) I fine tune my setup, check with the nursing staff in the room, and when the entire team is ready, I bring the patient in.

7:25am - The patient is on the table and we're ready to induce. My attending comes in and introduces himself, we induce general anesthesia, and we intubate. As I'm securing the tube, the surgical attending compliments my facility with the nasal intubation, saying I did it "perfectly." Perhaps this is some kind of Stockholm Syndrome, but for some reason, the fact that the surgery team is actually valuing my work makes me really happy, even more so than the fact that my own attending told me I did a good job. There's usually this undercurrent of antagonism between surgery and anesthesia and after a few months you start developing a thick skin.

9:00am - The patient has been fully prepped and the surgery has begun. This type of facial surgery can be extremely bloody, so in order to minimize blood loss, we often deliberately run patients at a lower blood pressure than normal. I set up my sodium nitroprusside drip for this purpose and get that going.

9:30am - My attending comes into the room and relieves me for a 15-minute break. I know this is some huge source of sniping between the surgical residents and the anesthesia residents, the fact that we get breaks from the OR whereas they do not. I really don't know what to say to that, except that I'm glad that I get a chance to go to the bathroom and grab a quick snack, and it does help me to stay more focused and vigilant during the case, which is the name of the game. I happen to think that anesthesia as a field is very collegial, and that there's something very civilized about getting residents out for lunch and to the bathroom. We work hard, but we're treated like people, you know? I quickly run to the bathroom and eat a Pop Tart. (Not at the same time, though.)

10:00am - The case is still proceeding, the blood pressure is where I want it, and I start to plan my wakeup. I want my patient to wake up relatively quickly after the surgery is finished, but calm, not thrashing, and ideally reasonably lucid, since his jaw is going to be wired shut and I want him to be able to breathe without getting panicky. I decided before the case that I wanted to have him breathe off the gas and run him on a nitrous-narcotic technique, so I start titrating in some morphine and begin adjusting my gas flows. I also start getting my setup ready for the next case, pretty much similar to what I did before the first case in the morning.

11:00am - The surgeons are putting their final stitches in, and I'm getting ready to "land the plane," as I always think of the process of emergence. There is much flipping of dials and pushing of buttons, and I give my reversal agent and suction out the patient's stomach. I give my full arsenal of antiemetics, since, with a wired jaw, I really don't want this patient to be nauseated and puking in the recovery room. I've titrated in some morphine for post-op pain, and I've gotten the patient back breathing. The drapes are finally down, and I call his name once. He opens his eyes, follows commands instantly. The tube comes out, and we're off to the recovery room. I ask him if he's in pain, and he shakes his head no. "That was gorgeous!" I say to no one in particular.

12:30am - The whole song and dance again, and now I'm in the room with my second patient of the day. Only I think I may be being punished for how well things went with the last case, because I'm having a lot of trouble getting my tube in this time. The patient has midface hypoplasia, and her crowded anatomy is giving us problems. After some struggling, we end up calling for the fiberoptic scope and intubating nasally with that. Thank goodness for my calm, experienced attending, because while we were never in true emergency mode (we had a good mask airway, and if push came to shove, we always could have intubated orally, though that would have precluded being able to do the surgery) I was kind of sweating.

2:00pm - My attending gets me out for a lunch break. I catch him up on how the case is going, and run out to scarf a sandwich.

5:30pm - The case is wrapping up, and I'm planning my extubation again. I worry about the nasal trauma we may have caused with our intubation attempts, but luckily the surgeons decide not to wire the jaws shut on this case, so that's something, at least. It's a smooth wake-up, and after making sure she's stable and comfortable, I wheel the patient to recovery. I fill out a "difficult intubation" form letter for the family (it's basically something for their medical record to appraise future anesthesiologists for furture surgeries about airway problems encountered), but I want to explain to the family exactly what the letter is about. I give the PACU nurse my pager number and ask her to page me when the family comes by.

6:00pm - Since I'm on call overnight, I go relieve another resident from her case. It's an ortho case done under general, pretty straightforward, and I watch the ortho residents (one of whom is my friend Guillem) complete the case and close over the next hour. I extubate without incident and wheel the patient to the PACU, where she complains of a lot of pain, despite getting some hefty doses of narcotic. I check the chart and note that the patient has a history of drug abuse and chronic pain, so I tell the nurse and change her post-op orders around to cover her higher drug requirement. I ask the ortho team if they would like me to write her for a PCA, which can often be a blessing for these pain patients (and for their caretakers), but they don't want one. Oh well, I offered.

7:00pm - In the PACU, I see my Team Captain (TC, the third-year resident on call), who tells me that there's a liver transplant scheduled for that night, send time at 3:00am, cut time at 4:00am. I ask the OR desk which room the transplant is going into, and start gathering the equipment that I need. In the middle of this, I get paged to the PACU, and head over to talk with my last patient's family. The patient looks a little swollen, but gives me the thumbs up when I ask her how she's feeling.

8:00pm - After grabbing a quick bite, I relieve one of my junior residents so that she can eat. We are having burritos tonight, a treat from our overnight attending. I take care of her patient in the meantime, who is having a revision of an A-V fistula.

9:00pm - I get paged that our TC is down in cath lab and needs some help. I run down there and see that they have called us to administer anesthesia for a stat cardioversion for a patient in A-fib. The patient looks like he has a terrible airway, and is so fat that he looks almost completely spherical lying on the table. I run upstairs to get the fiberoptic scope so that we can have it on standby. I manage the airway while my TC pushes the meds, and luckily it all goes without incident. My TC tells me that there's another patient going for emergency cardiac surgery tonight, but that the cardiac call team isn't in house yet. Would I mind helping to get that case going?

9:30pm - I am setting up the room for the cardiac case, which, of course, is completely trashed from the case before. I have the machine set up and I am just loading the drips when the cardiac call resident gets in from home. I stay a while to help and make sure she has everything she needs, and then go back to my other OR to finish setting up for the liver transplant.

11:00pm - I've finished setting up for the liver. Except for the cardiac case, all the other rooms are done, and all the residents on the call team have gotten a chance to eat. I pre-op my liver patient, make sure that the liver attending has been updated, and jog over to my call room to catch a quick nap, setting my pager to wake me up at 2:30am.

2:45am - I'm back in the ORs, giving my room a final look and talking to my transplant patient. She is very jaundiced, but otherwise seems reasonably healthy and in good spirits. We say goodbye to the family and head on back to the OR.

3:45am - The patient is induced and we have her all lined up (meaning one large peripheral IV, two A-lines, a double lumen CVL and a Swan). As the surgeons start, we draw off a baseline set of labs and start checking all our blood products, 10 units of PRBCs and 10 units of FFP. For patient safety, these must all be checked and double checked by two physicians before being given, and then triple-checked right before we actually hang the bag. The patient is a little coagulopathic, so I give her two units of FFP through the rapid-infuser fluid warmer as the surgeons are dissecting. To attempt to minimize bleeding, I also try to run the patient a little on the dry side until we get closer to cross-clamp.

5:30am - The patient is stable, running on some low-dose pressors, but otherwise doing beautifully. My attending comes by to give me a break. I get a drink of water, check my e-mail, and quickly do some other things.

7:15am - I am now officially post-call, and after giving signout, I am relieved by another resident. I go to the locker room, change, and start walking towards the subway, excited because it seems like a pretty nice day out, and I plan to take Cal out to the park. Hooray for the Bell Commission.

The reason I decided to tell you about my day was not because of the comments or general misconception that anesthesiologists basically get paid to sit around and do nothing. OK, so maybe that was partially the motivation, but I really just wanted to underscore one thing. We are all medical professionals, and whatever our role is in the patient's care (anesthesia, surgery, medicine, nursing, what have you), in the end, it's not really about us and our pride. It's about the patient. I really don't mean to sound Pollyanna-ish in saying that, but there's no other way to really state it plainly. It's not about us. We all have the same goal, and that is to take care of our patients well and get them home safely and to feel at the end of the day that we did the best job we could.

I wrote in the past how a neurosurgery resident accused anesthesiologists of "having no ego," and while part of me bristled a little when he said it (though I 100% agree that I had less ego than he), part of me thinks, damn right. I don't want to have ego when I'm working. I mean, not that I want people walking all over me, but the point is that it's not about me. It's about the patient. And since we're all supposedly working with the same goal, why are we fighting all the time? Push out the jive, bring in the love.

(But make no mistake, talk smack about me to my face and I will cut you.)

also, no booze or heavy machinery

This evening Cal developed itchy hives on his face and neck, some kind of allergic reaction to something or other. Joe suggested we give him some children's Benadryl. Having sampled the Benadryl elixir myself a month ago to assure myself that it was not poisoned by the Chinese, I agreed that Benadryl sounded like a reasonable idea, especially close to bedtime as it was. As a Peds resident, I had prescribed Benadryl hundreds and hundreds and hundreds of times, as will know until my dying day that the pediatric dosing is 1mg/kg and that Benadryl elixir comes 12.5mg/5mL. So given that Cal weighs about 30 pounds, I recommended that Joe give Cal one teaspoon, or 5mL, of the Benadryl. It's slightly underdosed, but I'd rather round down than round up.

A few minutes later, Joe comes wandering back in holding the Benadryl bottle.


JOE
So maybe we should only give him 3mL.

MICHELLE
Well, maybe if you believe in homeopathic dosing of Benadryl, but at that dose, what's the point of giving it at all? It's barely going to do anything. Anyway, it's just a one-time dose.

JOE
On the box it says, "for children under six years, ask your doctor."

MICHELLE
Honey, I am a doctor, and I am telling you that the dose is 1mg/kg.

JOE
But he's under six! The box says!

MICHELLE
Please believe me that this is the right dose. It's practically the only piece of information I've retained from my Peds residency. Let me use it.


Actually, that's not entirely true. There is one more piece of dosing information that will forever be burned into my brain. Probably for the rest of my life, even if you wake me up from a dead sleep, I will be able to tell you that the Pediatric dosing of PO Tylenol is 10-15mg/kg, and that the regular strength elixir comes in 160mg/5mL. Old reflexes never really get extinguished.

(Perhaps it would be prudent at this point, upon recommendation from my legal department, to include an addendum. For dosing recommendations for your own child, please consult your real, non-computer health care provider. There are a host of other issues that could possibly affect the dose your child gets outside of their weight, so don't just go by these numbers. But you knew that.)

i'm with stupid

The hospital sometimes feels like just a giant festival of assigning blame and stupidity. Such conflict. Surgeons think that anesthesiologists are stupid. Anesthesiologists think the surgeons are stupid. The nurses think the doctors are stupid. Everyone thinks that the ER is stupid. And then there is yelling.

But we can't all be stupid, can we? How would we be here?

relief station

Our department is the only place I've ever seen refer to their bathroom as a "relief station."

in the still of the night




The good thing about starting a liver transplant at 3:00am is that you get to do all the fun stuff starting up the case--all the induction and lines and cross-clamp and whatnot--but not necessarily have to stay for the six or eight or ten hours it takes to finish the case, because by that time, you'll be relieved by another resident post-call.

The bad thing about starting a liver transplant at 3:00am is that it's 3:00am.

on the subject of hypocritical doctors...

Breakfast of champions. (Do as I say, don't do as I do.)

we've got a lot of explaining to do

Cal wants to know why we've been holding out on him.

How is it that all this time, there has been a show about trains--not only trains, but TALKING TRAINS WITH FACES, Liverpoolian*-accented vehicles who engage in petty rivalries and backbiting all while saying terribly proper things like, "Dear me!" and "Oh bother!"--and all this time we never told him about it?

For shame, world, for shame.

And that even his own parents, who had heard about Thomas the Tank Engine from other grown-ups, hadn't investigated such programming, because they wanted to spend "quality time" with him and wanted to do right by his education and growth, under some vague AAP-fueled notion that too much TV time was not good for kids?

Folly, grown-ups. FOLLY.

Cal would like to continue on this line on inquisition, however, he has a lot of episodes of Thomas to catch up on.


Currently reading: On a related topic, thousands of Thomas toys have been recalled due to the discovery that they were embellished with leaded paint out of China. Yes, China again.

* Apparently, it's actually Liverpudlian, not Liverpoolian. Bollocks!

shave and a haircut, 3000 cents

I took Cal to get his first (professional) haircut today. He was just starting to look too much like Ringo Starr, and I thought that a shorter mop might be better for the summer. As you can see, he was not impressed, though I think he looks handsome, and much older somehow.



We went to Doodle Doos down in the Village (you can click on that link, but don't get too excited, their website consists of only one page, a flier really) which was actually very nice and child friendly. There was a person down there (the hairdresser's assistant? The kid wrangler?) whose sole job was apparently to run interference--pointing out Those Funny Things that Steve was doing on Blue's Clues or blowing child-diversionary bubbles during critical moments of the coiffing process. I could have served that purpose myself, but she seemed to be having so much fun doing it that I just let her go crazy.

Cal was overall pretty good. The only parts he really didn't like were the parts where she was trimming his bangs (too much hair falling on his face), and the end, when she was cleaning up his hairline with the buzzer. Otherwise, smooth sailing. Since it was Cal's first pro cut, they even sent us home with some of his hair in a little box, which was a nice thought (maybe if we want to clone him?) but that even a sentimentalist pack rat such as myself will likely chuck into the trash.

He looks good. Not that I'm particular about hair or anything. My instructions to the stylist were (verbatim) "Maybe shorter, but not, like, G.I. Jane or anything." And I have been letting Cal run around looking like Moe for the past few weeks.

Dude, he's going to pick up so many chicks now.




In errata: I just got an e-mail from Ken (and I think that there's actually someone in the comments section that mentioned this too) that there actually is a medical Wikipedia that is written and edited by physicians, called "Ask Dr. Wiki". I think they're still amassing their content, which is probably a huge undertaking, but it looks like the eventual goal is to be sort of a free version of Up To Date. Which, if accurate and well-written, I can really get behind, because, woo! Free! Thanks for the e-mail and setting me straight, I actually had no idea that there was a medical Wikipedia beyond the regular one.

the hypocritical oath

So I probably overreacted with the petichiae thing, but dude, PETICHIAE. It was right to bring him in to the doctor's office (my first walk-in visit ever), and it was right to have the scary things on the differential, though perhaps not constructive to freak out that we were on the road to Waterhouse-Friderichsen syndrome or some such thing.

What this whole episode has emphasized to me, actually, completely unrelated to petichiae, is how hypocritical we in the academic medical community can be. Well, maybe I shouldn't generalize. It has made me realize how hypocritical I am about being a member of academic medicine. Look, I'm a resident. I may be a doctor, but I'm still in training, and still on the steep part of the learning curve. When it comes down to it, I am learning on my patients. I am practicing my skills on my patients. I don't have the experience of my senior attendings, and undoubtedly I make more mistakes than these attendings. But this is how the system works. This is how the system perpetuates. My patients come to [University Hospital] for the higher level of care that an academic hospital provides, but implicit in that is an agreement that they will be participating in the education of medical students, residents, and fellows. We need our patients to buy into this system, and for the most part, it works out well.

But then when it comes time for my family to come into the hospital, or if my child gets sick, I don't want to buy into the system of which I myself am a part. I want to skip to the top. I want the attending. And not even just any attending, I want the senior attending. I want the one with the grey hair and the 30 years of experience who trained in the days of the giants and who has seen everything at least 600 times before. I will let med students in the room and I will chat with the intern and I will let the residents do whatever scut needs to be done, but when that needle's coming at my back, or when (god forbid) it's my child going under the mask, I want the very best, most experienced person to be involved.

I realize that this probably makes me not only a total hypocrite, but an asshole as well.

I know I'm not the only one that feel this way, though. Every day on the anesthesia schedule, there are cases labeled "ATTENDING REQUEST," wherein the skills of specific anesthesia attendings are solicited for particular patients. Sometimes it is the surgeon doing the requesting, but much of the time, the patient making the request is actually an employee of the hospital--a nurse, an doctor from another department, someone from the billing office--or a relative of a hospital employee. People who work in the hospital get to know who they want taking care of them. I myself already have a list in mind for who I will go to if anyone in my family needs cardiac surgery or what have you, and who would be doing the anesthesia for those cases.

I've had patients, giddily floating out of the ether cloud, tell me that the next time they're in for surgery, they want me and no other to do their anesthesia. That's very nice of them to say, but I can tell you, there are very few, if any, "resident requests" on the schedule.

So the question is, is it fair for those of us on the inside to be able to pick and choose who we want to manage our care, while we expect our patients to put up with what's doled out to them because they're at a teaching hospital? Is it moral to use our pull and access to the system to get what we feel is the best possible care for those that we love, and yet expect everyone else to play by the rules?

Last week, I was with a medical student on a day of doing straightforward cases on basically healthy patients under general anesthesia. That day, I wanted to give the medical student a chance to put in an IV. It was the end of third year, she said she had put in an IV successfully just the day before, I selected a nice young, skinny patient for her to try on, and I gave her a 20 gauge, which (for you non-medical types) is a small needle. Basically, I wanted to maximize the med student's chances of success, because then it's a feel-good experience for everyone. The med student had introduced herself to the patient out in the pre-op area, and then we all walked back to the OR, where I got the patient up on the table and set up all her monitoring. I set up all the IV stuff, put the tourniquet on the patient's arm, swabbed with alcohol, silently indicated a couple of good veins to aim for, and then discreetly stepped aside to let the med student start the IV. I didn't make a big deal of it. I didn't say to the patient, "Now I'm going to let our med student start an IV." I just stepped aside and let her try.

What happened was this: the med student hit the vein, got a flash, but probably her approach was a little too steep and the needle went through and through, leaving her unable to advance the catheter. I must have done this many, many times myself when I was learning to start IVs, but after you screw up a couple of times you modify your technique and you eventually get it right. I tried to help her adjust position, but the vein was already blown, and it became clear that we would have to try again.

"What are you doing?" the patient started asking. "Why is she doing the IV? What is she, an intern?" She looked at me. "I want you to do it! You put it in!" I didn't say anything about the "intern" remark (figuring that it would only make things worse to remind the patient that the "intern" in question was in fact two years junior to an actual intern) but just quickly stepped up, slipped in an 18 gauge, and said in a cheerful voice, "Absolutely. Done. Now, what do you say we get you off to sleep?"

The patient calmed down and we induced general anesthesia without incident. After the tube was in and taped, I turned to the med student, who looked like she felt bad. "Don't worry about it," I told her, "you'll get the IV next time." We talked about her approach, how she could take a shallower angle next time, how to advance the catheter using just one hand instead of two, and that was that. As one attending told me early last year as I was berating myself for screwing up something or other, "You're supposed to make mistakes. If you could do everything perfectly already, you wouldn't need residency."

Obviously, this is true. Also, it deserves to be said that attendings can make mistakes, and resident can perform at incredibly high levels. But it does make me uncomfortable sometimes, thinking how much less I knew when I was an intern, or even as a first-year anesthesia resident, and how much responsibility I had at that time anyway. And it also makes me uncomfortable to know that if Cal had been the patient that day, surely there is no way that I would have let a needle-wielding medical student anywhere near him.

(And don't call me Shirley.)

Currently reading: "Incidental Findings." Did you know that Danielle Ofri wrote a second book? Neither did I, until today. Her first book, "Singular Intimacies," is about her medical training at Bellevue (and not, despite the title, about masturbation).

petichiae

When Cal woke up this morning, I noticed that he had scattered petichiae all over his left hand, extending up to the wrist with a few spots on his forearm. There were no spots anywhere else on his body, and he was otherwise totally normal--happy, playful, no fever. But still, PETICHIAE. Lord. I went through my differential at once.

Best case scenario: some sort of unmonitored traumatic injury somehow. (Ponytail holder around the wrist? Sleeping on his arm funny? I don't know.)

Kinda bad case scenario: ITP, or some other scary unnamed reason for thrombocytopenia.

Worst case scenario: I can't even say it.

Granted, my level of alarm is somewhat skewed, as I have very vivid memories from my internship of taking care of a patient with fulminant meningiococcemia. He survived, but only after weeks in the ICU with Xigris and pressors and needing to get three of his four limbs amputated. Oh yes, not alarming memories at all.

I really weighed whether or not I should go into my regular pediatricians office or just call ahead to my homies in the Peds ER telling them I was on my way. But I decided that given Cal's otherwise completely normal appearance of robust health, I would try to take the non-alarmist route and lean away from going the route of maximal interventions by just taking him as a walk-in to the Pediatrician's office first.

The doctor we saw wasn't our primary, and--this is terrible of me to say this, what a hypocrite I am--she was probably only a few years out of residency, so I was immediately wary. She agreed that he looked well, and given that the petichiae hadn't spread anywhere beyond his left hand (I had very carefully circled the ones I noticed at home with a fine-tipped Sharpie, so that I could keep track), she figured that it was probably a result of some occult injury that we didn't catch, because Kids Do The Darndest Things and we really aren't on top of him 24/7. I would have felt better with a platelet count, but he doesn't have bruising anywhere else, even parts of his body that I witnessed him crunching and slamming just yesterday, so maybe the myriad etiologies of thrombocytopenia are less likely. "But if he starts to look worse, or gets a fever, obviously call us back," the Pediatrician told us. I smiled and nodded politely, but in my head, I was thinking that if I felt that anything at all was going south, I wouldn't be wasting my time trying to get through to the office's answering service, I'd be calling the Peds ER telling them that I was on my way over there postehaste. I don't have time to dick around, here.

Cal is fine. He had a fun start to his day (what with taking a taxi ride and a subway ride), played all morning, had a big slice of pizza for lunch, and now is sleeping. I'm glad, because by this point, I am mostly convinced that the petichiae was the result of some sort of mechanical injury. But still hard not to feel a little uneasy. I've seen too many bad things.

Sometimes I envy regular patients. Patients who don't know anything about medicine. Patients who trust their doctors. If I've learned anything from my four years of residency so far, it's how often doctors can be wrong.

dr. wiki

A couple of weeks ago, when I was still on my Pain rotation, a group of us were discussing something about drug dosing (the equianalgesic dosing of ketorolac as compared to morphine, if you must know--yes, and now that you are fully asleep, I can steal your wallet), and not coming to any sort of agreement as to what the actual conversion was.* Academic bickering turned into a library disassembling quest for some hard facts, as we started combing through all the available textbooks at hand for a conversion table. Only for some reason, no reliable conversion could be found, even in the old warhorses (Miller, Barash et al.). Which meant that it was time for the secret weapon.


MICHELLE
I think it's time to ask Dr. Google.

RESIDENT #2
Oh yeah! Google it!

MICHELLE
Maybe there's some research article that we can pull up.
(Typing)
Oh wait, here's some random Korean study that shows the Toradol:mophine ratio is about 1:6. That sounds about right. Let's go on PubMed and see what else is out there.

RESIDENT #3
Forget PubMed and Dr. Google, man! Ask Dr. Wiki!

MICHELLE
Who the hell is Dr. Wiki?

RESIDENT #3
Wikipedia!

MICHELLE
Oh my god, please tell me that you do not get your medical information from Wikipedia.

RESIDENT #3
They have everything on there!

MICHELLE
Yeah, I mean, if I wanted to know everything there was to know about Diff'rent Strokes, maybe I would go to Wikipedia, but for chrissake, you're a doctor, man! You can't look up stuff on Wikipedia!

RESIDENT #3
I'm just saying, they have everything on there.


Hey, I love me some internet, and I don't know how people did research and traded information without it. But man, trusting Dr. Wiki is taking it one step too far. He's like the chiropractor that takes out ads on the subway.

(To his credit, I think that Resident #3 was kidding.)

(Mostly.)


[ * All of us had been told sort of anecdotally that 30mg of Toradol = 6mg of morphine, but Big Blue says 10mg of Toradol = 6mg of morphine. This was the only text we could find that stated the conversion so baldly, but we had a hard time believing it, since a.) Big Blue is notoriously full of typos, and b.) We usually load with 30mg of Toradol in the OR, and no one's experience has been that it provides anywhere near the analgesia of 18mg of morphine, or even 10mg of morphine. It's a great adjunct to the opiates we use (when not medically contraindicated), but I haven't had many post-surgical patients totally comfortable on Toradol alone. Maybe other people have different experiences?]

also still alive




I saw the baby bird hopping around by the apartments down the street this morning. Looking feisty. Cal and I will bring him some breadcrusts when we head out tomorrow.

(Oh yeah, I'm on vacation this week, did I mention? Hence all the time to feed and photograph the local wildlife.)

before you start sending flowers




Cooper wants to let you know that after the false death rumors instigated by yesterday's entry, she now knows how Paul McCartney felt after the Abbey Road album came out.

the extreme truthiness school of parenting

On our way down the block this afternoon, Cal and I passed by another mom with her two kids in a double stroller. They were looking at a baby sparrow on the sidewalk. It was a baby sparrow, but not a baby baby sparrow, with the damp matted feathers and membrane-sealed eyes and seeking mouth. It was an old baby sparrow. It had mature feathers and it was hopping around the street chirping and everything. The only way that you could really tell that it was a baby was because it was very slightly smaller than the average sparrow, and there were still a few tufts of down back by its wings. I don't know if it had fallen out of its nest, but it seemed just as likely that he had gotten kicked out, like a teenager who just hit 18 and whose parent decided they just couldn't take his freeloading anymore.

The other mom seemed to have her own set of thoughts on this, though.


MOM
Look, it's just a baby.

TWO YEAR-OLD
Baby bird!

MOM
Yes honey, that bird is going to die.

TWO YEAR-OLD
(Dismayed)
Die?

MOM
(Firmly)
Yes, the bird is going to die.


Now, whether or not the bird is going to survive is certainly up for debate. I mean, that would be the case even if it was a full-grown sparrow, because this is New York City, and it's a bird-eat-bird world out there. But is this one of the hard truths that you want to point out to your toddler while out on your afternoon constitutional? I'm all for truthful parenting, you know, no stories about how babies grow in the cabbage patch instead of telling kids about S-E-X, or how we gave Cooper away to a nice family with a big farm instead of admitting that she ran under a bus. (Although: if you are a nice farm family, call me! Free dog!) And not that I'm one to judge, since I've never had to tell Cal anything difficult. But I don't know, I guess I don't have the heart (or the balls) to not sugar-coat things somewhat.

Anyway, my point is not to incite ire, which inevitably happens when one parents questions another parent's approach to anything involving their kids. And who knows, maybe the mom and her kid were just in the middle of a larger lesson about life and death or what have you. My point is that I'm rooting for the sparrow. I think he's going to be fine, frankly. There's an old lady who lives in the apartment building just a few feet away who routinely sprinkles out birdseed and breadcrumbs on her air conditioning unit. Not that I recommend that, because, guh, histoplasmosis, but it's nice of her anyway.

sunday times

It seems like the summers in this neighborhood are just one constant street fair. Yesterday there was a street fair down Second Avenue, and today there's one up Third Avenue. It wouldn't be so bad if they still had that family that sells the kettle corn, but I haven't seen them for months now. Where are you, kettle corn family? There's only so much room for Gyros and grilled corn on the cob.

We had to drop by Bed Bath and Beyond this morning to pick up something (something of the "Beyond" variety--a picture frame, if you must know), and we tried to sweeten the deal for Cal by getting him a box of animal crackers shaped like a bus. He was disinterested in the cookies themselves, but very interested in the box, which he insisted on driving along every building on the street until it got dragged into a puddle of offal and crushed.




And yes, between the jean jacket and the Converse sneakers, he does look like he's going to challenge some other kids to a breakdance contest. He just needs his boombox and flattened out cardboard box first. Word.






Isn't it funny how different playgrounds have different personalities? There are a couple of playgrounds where we usually bring Cal, one which has a distinctively yuppie vibe (which actually conveniently gets kind of empty on summer weekends, as it is a Hamptons-type crowd), and one which is more middle class, located in the center of a large housing complex. Today we went to a different playground at Union Square, which is a little seedier than our usual haunt (see: empty Bacardi bottle behind the chicken wire, scary sandbox with yellow caution tape perimeter--however, no effluvia of spilled beer and puddled urine, like the really seedy playground across right near our apartment) and which gave out kind of a hippie vibe. Long-haired dads, sandals with socks, lots of interracial families, that sort of thing. It was unabashedly run-down, but nice in its own way, kind of like an old VW bus. (Those vehicles, incidentally, always remind me of the plutonium-wielding Libyans in "Back to the Future.")

Speaking of long-haireds, I'm looking at those pictures of Cal and I see that he needs a haircut. Again. Maybe that's why we fit in so well at the hippie playground.

souvenirs

I noticed this afternoon that Joe had thrown away his old short white coat, from back when we were med students. Though I am loathe to throw anything away (which explains my not insignificant problem with clutter), I did not begrudge him for trying to clean out his closet. However, I noticed that he had left his old name tag attached to the coat, which I thought surely was an oversight. This was a collector's piece, a souvenir item. So I rescued it and put it on the kitchen counter.




Later that afternoon...


MICHELLE
Oh, you accidentally threw out your old med school ID tag, but I rescued it.

JOE
Yeah, I saw that on the table. I threw it out again.

MICHELLE
Why would you throw it out? Wouldn't you want to save that?

JOE
(Perplexed)
Why?

MICHELLE
Because...because it's nostalgic! Your old med student ID tag! Don't you want to save that? Think how cool that'll be, when you're some old crusty attending, to have your med student name tag from the turn of the century!

JOE
Not...really. Why would I want that?

MICHELLE
Well, why do people save anything? Why do you save your med school diploma?

JOE
I need that to get a job.

MICHELLE
OK, bad example. Why do you save your graduation tassels?

JOE
I didn't.

MICHELLE
You threw out your med school graduation tassel?

JOE
Well, I don't remember saving it. What would I do with it?

MICHELLE
Look, if I have to explain why you would save something like that, you probably wouldn't understand anyway.


So now internet peoples, tell me: who is crazy? I am inclined to point the finger at Joe, but when I really sit down and think about it, I can't really think of a way that excessive sentimentality is a particularly adaptive mechanism either. And it certainly makes my desk messy.




Above: My med school name tag, along with my graduation tassels, from (L to R) elementary school, high school, college, and med school.

aural surgery

The other day, I was in a case where the patient brought in her own iPod. Apprently her daughter had made her a special playlist, and wanted to have it playing during the surgery. The surgeon was a good sport about the whole thing, since the case was under MAC, and agreed to hook it up to his portable speakers.

But it wasn't until the patient was being induced that the surgeon thought to ask, "So, how old is your daughter anyway?"

"She just turned fourteen."

"Hmmm." The surgeon looked like he was starting to regret granting her request. And after the second hour of listening to Hillary Duff and Avril Lavigne, we all sort of were.

don't tell al gore

It's scary how much trash we generate per day at the hospital. This is just from me setting up the room this morning, and we haven't even started the case yet.

pre-emesis

Another night on call, another dinner in the hospital.

but the bag really makes the outfit




I was doing off-site anesthesia yesterday (meaning anesthesia outside of the ORs), basically running around to various units providing my services for traches and cardioversions and such. I was carrying one of the big orange arrest bags with me as I usually do when I'm off-site, which contained all my mobile anesthesia stuff--meds, tubes, emergency crap. Walking into the MICU with my big bag for the next trache on the schedule, I passed by one of the cardiology attendings, who was leaving the unit.

He stopped dead in his tracks when he saw me. "Oh no," he said, alarmed, and started to move out of my way.

It took me a few seconds to realize that the reason he looked at me like I was the Grim Reaper was because not because of me, but because of my bag, which is same one that we bring when we get called for stat intubations and codes. (Code Blue, that is, not, you know, Code Brown. Thankfully, anesthesia services are usually not summoned for those.)

"Don't worry," I assured him, "I'm not here for an arrest. Everyone's OK." He looked somewhat mollified, but still concerned as I rounded the corner, the neon orange arrest bag bouncing on my hip.

Man, who knew it would be so easy to spook people? I should bring this bag with me everywhere, just for intimidation purposes.

your civic duty

OK, so this post is for purely selfish purposes. As noted previously, I am among the many people who are unduly fascinated with the t-shirts at Threadless. It's not like I don't have enough t-shirts, but these t-shirts are cool, and also superior to nudity (mostly). OK, exposition: how Threadless works is that people can design t-shirts and submit their ideas. The designs get voted upon by the general populace, and the most popular designs get printed. Sometimes the t-shirts are very extremely coveted and sell out, after which point you can either mourn the fact that they are gone forever, or you can vote (yes, more voting) to get them reprinted. This is, I'm sure, what the founding fathers were envisioning when they founded our fair democracy. Voting for t-shirts.

Anyway, there are a few t-shirts that I have been voting for to get reprinted, but I am just one small voice. (Reminder to self: talk about "One Small Voice" at the end of this entry.) But I thought to myself, "Self, if we just post pictures of the designs, might not other people be interested in voting for them as well? And might not the mighty chorus of internet voices eventually lead to these designs being reprinted? And might not the reprinted designs possibly be available by late fall, making me the best and most thinking-ahead Christmas shopper ever in the history of EVER?" I had to admit that I was right. AS USUAL. So anyway, without further ado, here are the t-shirts that I am campaigning to have brought back. You can click on the designs to see them big, and then if you like them, you can vote to have them reprinted, which would be GREAT. (Don't worry, you don't have to buy anything. Unlike the presidential election, your vote is free.)



This t-shirt is funny to me, although I'm sure someone will say that it's racist somehow, because not all cowboys are white and have lassos, GOD.



This t-shirt is funny for medical people because it's all about coronary artery disease and hyperlipidemia, which is a serious, serious topic, but look how cute that can of lard is! With the rubber mallet! Ha!



I think Joe would like this t-shirt. As would your friend who likes bacon. And hot dogs. And clown flesh. In addition, the artwork reminds me of Chris Ware, who is my favorite.



And this shirt is...I don't know. It's just random. But I'm hoping that they reprint it in kids sizes, so that I can get one for Cal. He wears clothes quite often.

Fine, ending shameless prostitution. But I just really want these shirts to get reprinted, OK? I will stop at nothing. Well, maybe I will stop at murder. But otherwise, NOTHING.


* * *


OK, so "One Small Voice." Back in the days of yore, I used to be editor-in-chief of our high school newspaper. Which actually was not a big deal, because our high school had something like six newspapers. There was one, the "official" newspaper (which was called What's What--terrible, I know) and several others, including The Observer (a New York Times knockoff, very serious, but successful in that a good number of my classmates who wrote for The Observer actually do write for The New York Times now); The Forum (a political newspaper headed up by the one right-wing Republican in the entire school); and my paper, Witness, which was the school tabloid. Seriously, we were a tabloid paper, and we were awesome. Not celebrity-tabloid, like writing about That Thing Britney Spears Did (actually, Britney Spears was probably only about nine years old at the time), but just writing these ridiculous, sensational news stories, like about students that got mugged in the courtyard of the school (EXCLUSIVE INTERVIEW!) or about a box-cutter accident in art class (I believe that was our cover story that month, heralded by the headline "TRAILS OF BLOOD"). Anyway: awesome.

When I started with the paper, one of our features was a column written by a seventh grader (my high school was 7th through 12th grade), called "One Small Voice." The columnist, Sean, was supposed to highlight the plight of the underclassman. How it felt being the youngest students, starting a new school, learning to use deodorant, all that. I think it was kind of revolutionary, in that most of the columns in school papers were just sort of upperclassman ramblings either written to pad ones college application or crammed with inscrutable in-jokes between the writer and his (the columnists were invariably guys) friends. So yes, anyway, we had a column written by a seventh grader. And yes, it was TOTALLY WORTH IT, especially because the seventh grader's uncle or someone worked in show business somehow, and got us an EXCLUSIVE interview with Matt Groening. I got an autographed Simpson's publicity still and everything! Yeah, so that was cool.

Anyway, after Sean finished seventh grade and eighth grade, I sort of assumed that we were going to find a new columnist, not because he wasn't good, but because the point of the column was "One Small Voice," not "One Medium-Sized Voice." Only I didn't quite know how to break it to him, and he just kept writing those columns and handing them in. I suppose we could have just changed the name of the column to something else, but like I said, the whole POINT of the thing was that it was a COLUMN written by a SEVENTH-GRADER. Who cares about ninth-graders? No one. Not even their parents.

Anyway, it didn't really matter anyway, because we ran out of funding in the middle of the year and had to shut down the paper until Septever, when our grant was renewed. And I'm not really sure why I told you that whole long story, but there it is.

senior slump

I was starting to get kind of excited about being a third year, even if it has taken me four years of residency to get there. It's more responsibility, but that's kind of exciting too. I'm excited about being TC (team captain, you know) overnight, excited about the possibility of getting to cherry-pick the big cases, excited about the affirmation that time indeed passes, even in residency, and that I may even have learned something along the way. I don't know. It's just exciting. Like the senior year of high school. Anyone want to join yearbook?

However, also like the senior year of high school, there's probably an element of senior slump come June. The current third years, I'm sure none of them will hesitate to tell you, are ready to be done. They're just...done. Enough already. I was checking my schedule this morning in the anesthesia office next to one of our third year residents, who, after noting that he had three big cases in his room, turned to me and growled, "You're going to hate being a third year!" before stalking off in a huff.

Way to rain on my parade, man.

the 11,000 word update

(Since pictures are worth a thousand words. Aha! Math!)

It was another very nice weekend for our family, as both Joe and I were off. Joe technically is on call today, but it's a home call-type situation, not to mention his last call as a resident ever (as the senior ophtho residents don't take call the last month). So yea, there is much rejoicing in our home. Here are some pictures of Cal from the playground this morning, in case you forgot what he looked like:







Lord, that kid is getting big. It was a crowded day at the playground, but I actually like taking Cal to the playground when there are a lot of kids there, because I'm trying to toughen him up. See, Cal has something of a Gentle Giant syndrome, because while he is large as compared to kids his age, he's kind of a pushover, which sort of leads to situations in which he gets a little bit shoved around, and wherein thug hooligan children steal his toys. He will usually either shrug it off or look over at the adult in charge with a sort of trembley-lip scandalized expression, but I'm trying to sort of model how to negotiate these situations with mediation and compromise. And also, when the going gets tough, I just shove the jerk kids down the stairs and pretend that it was an "accident."

(Need I note that I am KIDDING? I would think not, but this is the Internet, so I will explicitly state that I have never shoved a kid down the stairs in my life. At least not one who didn't deserve it.)

On one hand, I am glad that Cal's personality is one that leans away from juvenile violence and such. Even though this sounds like I prefer the victimization of my kid, I have to say that I would much rather teach my kid how to avoid being thugged upon than to have my kid be the thug. However, I don't want Cal to be too passive or anything. This could just lead to a lifetime of him getting shoved into lockers.



After the playground, we went to the Japanese market, wherein I picked up this really good white bread that they have there (I don't know why the Japanese bread is so much better than the regular kind of bread that they have at the whitey supermarket, but IT IS. Maybe there's more butter in it? It does feel heavier than the loaves I usually get at the store) and to survey their snack collection. Nobody does snack food like the Japanese. They even had the full array of Pocky, including my personal favorite, "Men's Pocky."




As well as this weird snack which looks like feces in a bag:




And this snack, which if my high school French still serves I believe translates to "Cock of asses."



There was a street fair down Second Avenue today as well, so we did some cruising on our way home. I was, as always, on the prowl for some cheap bedsheets, but they didn't have any good sets out today. (I like the cotton sateen kind with the tone-on-tone stripes. A little more pricey than the super-cheap $10 sets, but very nice and still at a big discount.)



There were, of course, plenty of Gyro stands, with the requisite 80's era poster of Hooter's waitresses holding Gyros next to their faces.




If that doesn't make you want to buy Gyros, I don't know what will.


Currently watching: "Shopgirl." It was fairly true to the book, which I guess should be no surprise, since Steve Martin wrote the screenplay and played the character of Ray Porter himself. Even though I've heard that Claire Danes is a not-so-nice person in real life, I am fascinated with her face. It's like you can read every single emotion on it. It wasn't a great movie, but she gave a good performance.

Speaking of "Shopgirl": Threadless is having a big sale which ends today, though there is a possibility that they may extend it through tomorrow. I am mildly obsessed with their t-shirts, particularly for Cal, though I am aware that in buying him clever t-shirts I am just one step away from being one of those parents that stuff their kids into slogan t-shirts to serve as billboards for their own beliefs. So I suppose my belief is that nothing rhymes with "orange."