pushing paper and drugs

How come no one on Grey's Anatomy or scrubs ever has to write a chart? Or wait on hold on the phone? How come they never show the nurse saying, please put that order in the computer? Or, here is the form for that? Or, you have to fill out this paper to bring this patient to the CT? Or, no, you can't have that medication without filling out this form. How come when Dr. Mc Dreamy says, Did the patient get an MRI no one hands the intern ten papers to fill out to get the MRI, the MRI is magically done? Yes, we do see the doctors pushing the patients down the hallway, but do we see them doing their real job, which appears to be pushing paper?

At home, my mom asks me... do you know who the interns are on this show? Do you know the story? Grrrrr. Don't spoil it for me mom, if you talk during the show I won't know what happens at the end... I am waiting with baited breath for the paper pushing doctor to appear.

Post Turkey Tryptophan Toxicity

The Journal of a Gypsy Doctor

Yesterday I came back from my first 9 day vacation away from the emergency department. It was turkey day, so my tryptophan levels must have been sky high.

I wasn't the only one with toxicity... My patient with digoxin toxicity: " Can you please gag the patient in the next gurney?"... Me: Gee, Attending, I think she might be a little altered, she wanted to gag the patient in the next bed... Attending... Maybe that's her baseline, maybe she's just cantankerous?

I guess I forgot how to be mean on my vacation, when I came back
yesterday, I was just like "oh you are standing in the emergency room
looking lost and you want to use the phone to call your cousin from
vermont? oh sure I can help you with that".... or.... " hi I am the
clueless surgery consult from upstairs and I can't find patient
booboohead can you show me where they are?, no problem, here they are,
let me drop what I am doing and log in to this computer terminal and
show you." Or the patient handing me a bottle of urine in the middle
of the chart writing area and smiling..grrr. several choice statements
and comebacks left my vocabulary for the past week... I felt aphasic,
I couldn't even name the peak flow meter to the nurse, I went looking
in the drawer for the puffer thing the patients blow into...I spent half my shift happily chatting to people instead of doing what I was supposed to do as an intern.... which is writing my notes, pushing paper, slipping x rays, calling primary doctors, calling the lab, waiting on hold.

I am arming myself with these for tonight... there is a public
telephone in the lobby... or... did you ask the charge nurse? did you
ask the consulting resident where the patient was? or... when you are
done with the urine, please hold on to it until I return...or.... this
is a chart writing area, although this counter looks like a desk in a
hotel lobby I am not your concierge nor will I be leaving a mint under
your pillow... or...in a more monty pythonesque vein (you have to see this movie to really understand this one) think of this counter more as a castle wall from
which I fart in your general direction.

I love the ploy where the ambulance brings in an unresponsive patient
and the third year resident says... ok, John do you want to
take this one, it will be a good experience for you, not quite a
stroke code but not much to do, just a bunch of stuff to get
cooking....Gee, I am kind of swamped... Oh we all are... we need
a stat CT Head, C spine, Portable chest, ABG, you need to talk to the
family, get those labs, check those labs, fill out that paper for the
CT, write the chart, consult the CCU and the MICU, and don't forget
about the other six patients you have.

Then there is attending number 1... Make sure you call that private attending and
discuss whether this man who walked here needs a stat MRI tonight or
whether he can wait till tomorrow. Why hasn't the radiologist called
back with the report? Radiologist.... Yes Call the sono lab, they are
reading the reports there. Lab... the patient is on the table still
getting the study which was ordered four hours ago... Sir, I am
sorrry, the report is not available because the patient is still
getting the study.
Then Attending number 2... I thought that patient was ready to go when
Attending number 1 signed out to me! I thought everything had been
arranged! Why is this patient still here?

Me. 10:30 pm, 14.5 hours after my shift began. Why am I still here?

Panaderia

Today I had Labor day off and went into the city. I stopped at the Mexican grocery across from my local Halsey stop and found some Mexican Pan. It was comforting to see the brightly colored bread, sweet on the inside, with the aroma of Mexico. I was reminded of trips to the panaderia in Rosarito Beach halfway to my grandfather's house in Mexico. And I had a thick Limon ice, which was delicious as I waited for the L train. What a glorious day. Que bien.

Hospitals and Subways

Is it just me or is it a little ridiculous for the NYU Joint Hospital to have a sign on a subway stop at First Avenue and 14th St... when that subway station doesn't have ANY handicapped access?

How exactly are the patients supposed to utilize that facility from the subway if they can't climb stairs?

Or that almost none of the subway stations in New York City have Automated External Defibrillators? And EMS personnel dread those calls to the subways. They have to lug three bags of equipment down to the subway when called to a cardiac arrest or medical emergency in the subway.

But far be it from me to comment... I am just a new to New York kinda guy.

Queen Square Patella Hammers

As promised, the experience of my final medicine OSCE deserves a blog post. Or rather, my SOSCE, which stands for Subjective Objective Structured Clinical Examination. We all got gussied up in our suits, struggling to find a place to lodge those Queen Square Patella Hammers, stethoscopes and penlights without looking like we were construction workers with massive utility belts. Honestly, there is no justification for the design of these patella hammers. There is NO good way to carry them around apart from poking a hole in your pocket and having them protrude ridiculously from it. Hence the phenomenon of doctors checking reflexes with stethoscopes.

We all sighed with relief with the announcement that funduscopy would not be required. Come to think of it, I would rather have used my ophthalmoscope with the eyes not dilated in broad daylight using the largest diameter setting than my Queen Square Patella Hammer. Which says a lot. May Gordon Holmes turn over in his grave (did you know he was Irish?). Here is another interesting pre-exam fact which Brian Hayes pointed out to me. Apparently Abraham Colles, of RCSI and Colles Fracture fame, was succeeded by Smith, who, apart from describing the opposite fracture, also performed Colles autopsy. Also, thanks Brian for pointing out that the glabellar tap is performed by percussion whereas the jaw jerk is performed with the patellar hammer.

clustr map

I am excited to have a clustr map on my myspace.

I was looking for people on myspace who live in far away and exotic places to add to my map, and I am disappointed most of you people who say you live in Greenland or Antarctica or Madagascar or the South Georgia Islands don't actually live there...if you know anyone who does, tell em to view my profile so I can get a dot from there.

According to Myspace there are 2308 inhabitants of South Georgia and the South Sandwich Islands between ages 18 and 100. I find that interesting considering that the South Georgia Islands and South Sandwich Islands (SGSSI) (further to the south-east) are a UK overseas territory see website. Continuous UK administration has been in place since 1908. At the height of the whaling period some 2,000 people lived on the island. Now there no permanent residents - but there are two British Antarctic Research Stations (Bird Island and King Edward Point), two Museum Curators and a Marine Officer and his wife.

Here is what it looks like ...

The Heard and McDonald Islands are also very far south... see website

If you are one of the 2039 estimated myspace residents of these places, you are just demonstrative of everything wrong with american culture. it's not an island so you can make a joke about big macs... currently there is no permanent resident population, and there are no ports or harbors... here is what really happened there: In the five years following the discovery of Heard Island in 1853, and of its reporting in newspapers around the world, more than 50 visits were made to land gangs on the island to kill elephant seals and render their oil.

Doesn't sound so cool anymore does it....

The killing and rendering of elephant seals at Heard Island commenced in 1854/55 and oil production peaked in 1857/58.

Following the near destruction of seals on the island by 1859, oil production continued until 1877. Up to this time more than 40 vessels, almost all from the north-eastern United States of America, had made over 100 voyages to the island.

The poor weather conditions at Heard Island and the lack of sheltered harbours along its coast meant that many vessels ran aground at the island, occasionally sinking in view of the sealing gangs that awaited their return.

There are few details of brief, sporadic visits to Heard Island by sealers and whalers in the early 20th century, and no records of sealing activities occurring on the McDonald Islands.

Now here is a little information about Christmas Island for the more than 3000 myspace residents of that Island who think it is a joke to say they are santa and live on Christmas Island (courtesy of wikipedia)

Since the late 1980s or early 1990s Christmas Island periodically received boatloads of refugees, mostly from Indonesia. These, and the occasional illegal fishing boat, were never a large issue, often welcomed by locals who looked forward to the exploding of the boats once the "boat people" had been processed. During 2001, Christmas Island received a large number of asylum seekers travelling by boat, most of them from the Middle East and intending to apply for asylum in Australia. The arrival of the Norwegian cargo vessel MV Tampa, which had rescued people from the sinking Indonesian fishing-boat Palapa in international waters nearby, precipitated a diplomatic standoff between Australia, Norway, and Indonesia. The vessel held 420 asylum seekers from Afghanistan, 13 from Sri Lanka, and five from Indonesia. The standoff eventually led to the asylum seekers being transported to Nauru for processing. Another boatload of asylum seekers was taken from Christmas Island to Papua New Guinea for processing, after it was claimed that many of the adult asylum seekers threw their children into the water, apparently in protest at being turned away. This was later proven to be false.

John Howard, the Australian Prime Minister, later passed legislation through the Australian Parliament which excised Christmas Island from Australia's migration zone, meaning that asylum seekers arriving there could not automatically apply for refugee status, allowing the Australian navy to relocate them to other countries as part of the Pacific Solution. As of 2005, the Department of Immigration has begun construction of an "Immigration Reception and Processing Centre", due for completion in late 2006. The facility is estimated to cost $210 million, and will contain 800 beds.

I don't think that's very cool.

As for the 1801 myspace residents of the Marshall Islands, I can only wonder why they want to live on a nuclear testing site.

Did you know that as of Dec 31 2005 there were more than 1.3 million US military personnel deployed in more than 100 countries? When you compare that to the estimated 10 million undocumented persons living in the US, I think it is silly to say for the US to say that there is a problem with undocumented people. I mean, for every armed American who is prepared to die to defend freedom and our way of life, there are 10 people who are living peacefully and just going about their business, living free in the USA. What's wrong with that? Just give em citizenship. Heck, give the whole world US citizenship. Why not. Whoever wants it should be able to get it, whoever doesn't want it doesn't have to have it.

I mean, seriously, if people on myspace can live wherever they want what's the big deal with a few immigrants?

Besides, most of the stuff we use in the USA is made somewhere else...

baby names and google

names

apparently it is all that to name your kid funky names. gwyneth paltrow and apple, the new cruise kid suri, grier from brooke shields. and who ever heard of pilot inspektor for a kids name.

ok but although according to freakonomics your name has no impact on your life, in google suggest this is not the case. Try it and see what your "Google Suggest Number" is...



http://www.jerrykindall.com/2004/12/10_google_suggest_number.asp

http://www.google.com/webhp?complete=1&hl=en

apparently there is even a google suggest alphabet, which on launch day was:

a: amazon
b: best buy
c: cnn
d: dictionary
e: ebay
f: firefox
g: games
h: hotmail
i: ikea
j: jokes
k: kazaa
l: lyrics
m: mapquest
n: news
o: online dictionary
p: paris hilton
q: quotes
r: recipes
s: spybot
t: tara reid
u: ups
v: verizon
w: weather
x: xbox
y: yahoo
z: zip codes

census

Sunday the 23rd is the Irish census. I filled out my section. According to it, I am Irish American, it asked me how far I travel to work and how, what my level of education is and if I volunteer. Quite comprehensive. And apparently you can be fined a substantial sum for refusing to participate. I wonder what happens if you tick the boxes wrong. Do the census police come after you?

The last push

It is late April. Where did the time go? I thought it would never go this fast. I have had a busy few months, obviously, since February 1st. I knew I was not going to match on Match Day due to the impressively "unresponsive to my pleas" errors of my medical school and the ECFMG. So, I ended up flying to New York City to participate in the Scramble. I negotiated the Scramble from my laptop computer inside a Kinko's on the Avenue of the Americas. I used my SKYPE phone to make phone calls, all from my computer. Then, when I finally got my c.v. through to some programs, being on the ground in the city enabled me to interview in person for a position. I lucked out being there, but since most of the unfilled programs were in NYC, it was a good strategy move in retrospect. I would have regretted not going.

One highlight of my visit was getting to see my grandmother. For a woman in her 90's she gets on remarkably well, continuing to drive! To think that the state doesn't enforce a night driving restriction on her, she only does that herself, makes you realize just why they were the greatest generation. How many younger people would voluntarily restrain their activities like that?

After coming back to Dublin, it was time for more study in preparation for finals and Step 2 CK. When I took this exam, some of the questions were just very tiring. It seemed like every question told you the patient's BMI and a whole slough of useless information, where you had to read the stem for the one significant clue. Several gems of questions focused on AMS people being brought in by concerned spouses and significant others. It was so formulaic it was ridiculous, but I really had to giggle at one question in which I was asked to discriminate the toxidrome of the munchies to determine what drug of abuse the significant other who had recently run out of an illicit substance, and had been avoiding work had been using.

I took USMLE Step 2 CK in London, got a chance to sit on the footsteps of St.Paul's and think about the last twelve years since I sat there last. When I was there last time it was 1994, I was 19, and just there for a year of study abroad. Now I am almost done with school, and it made me think, being there sitting outside that cathedral. Cathedrals take a lifetime to build, they are impressive in that way. Similar in many ways to professional education. Yet, I hardly feel like a cathedral.

Ah well. Also got a chance to pop over to the British Museum and have a look at the drawings of Michelangelo. He was pretty good at representing anatomy, apparently he wanted to publish his own drawings as he did dissections (but never ended up doing so) to make sure he represented the muscles correctly. As I was looking at his sketches that he did for the sistine chapel and for other works such as David and the Pieta, I began to realize that he had to do several sketches in advance, to get the perspective and points of view right. It became interesting to me when I thought about it, very similar to reading an x ray or CT in terms of visualizing in 3 dimensions. He would do sketches from points of view never visible from the viewers perspective, just to get the dimensions and sculpture right. It was interesting.

Here are Michelangelo's thoughts before he died. He was a fascinating figure. While I was in the British Museum, I had a peek at the Rosetta stone. It was a stone which enabled translation of ancient hieroglyphics. Fascinatingly, it only came into the possession of the British through military conquest. Speaking of military conquest, apparently things don't change much. I saw several exhibits of the Assyrians and other civilizations in Iraq in the British Museum. One of the exhibits displays a bas relief of some soldiers in a conquest in Iraq. The caption is telling, things don't change much. I just saw in the news that SIX retired generals have come out stating that Rumsfeld should resign due to his mismanagement of the war in Iraq. One of the interesting points I saw in the argument was that the civilian control of the military remains paramount to our democracy, but perhaps is very irksome to the retired generals who view his conduct as arrogant. Interesting, because as Republicans arrogantly state big government is bad, and the role of the government should be limited, this obviously doesnt apply to the way they run things, from Cheney shooting hunters to Rumsfeld's micromanagement.

One last note. Recently two commercial airliners were diverted from landing in the Irish Republic due to bomb threats. British RAF Tornado jets were scrambled to escort the planes to landing facilities in the UK. I find it somewhat interesting that in 2006, 90 years after the uprising in Dublin in 1916, the sight of RAF jets over Irish airspace is handled so well by the public. Particularly in view of the recent Dublin riots and the military parade on Easter Sunday. Yet after talking about it with my Irish friends, I realize the Irish Air Force has NO fighter jets. It is inconceivable to many Americans to live in a country without that. But, looking at the Irish Air Force, they really don't boast too much apart from the only Learjets in Europe.

Back in Dublin

Ok So I am back in Dublin and I have been back for like three weeks. It's nice being back in the hospitals, mostly, as in this picture, we medical students run around trying to find tutorials and read books and attend lectures that only half the time occur when or where they are suppposed to. Basically, its pretty stressful because you go in every day and you never know whether you are going to learn a lot or not. Some days you just want to stay at home and read, especially when you go in one day and only half your lecturers show up and half of the ones that do show up are a pile of crap. We are supposedly attached to teams but everyone is so busy that we dont really have any real responsibilities on the team. Its a pile of crap and its difficult to keep a good attitude. Anyways, apart from that, I met this girl on myspace who came to Dublin and she's pretty neat, I like her a lot, she lives in New York and I have been talking to her on skype, she's cool.

Back from Saginaw

Went to Saginaw Michigan for an interview, stopped in Grand Rapids to say hello to my cousin Marie Claire and Victor. Saginaw is the home of Dow Chemical... and not too much else. But the interview was cool, I had a chance to sing the fight song of UC Davis, of which all I know is the first line, which is "We are sons of California...", and all the campuses use the same song, but I think there are some particular Aggie/Mustang lyrics in there. Thats random, but I have never been asked to sing a song in an interview before. The other thing I was asked was who my favorite superhero was. I did some research the night before and I was going to say Finn Mc Cool who ate the Salmon of Knowledge, but figured what with the toxicity of the Saginaw River I didn't want to go there.

The Saginaw ED is cool, they have a great program run by the president elect of CORD, and their ED is on the cover of ED Design Guide put out by AAEM. They even have a toy train in the pediatric procedure room, and each pediatric room has a fish tank! Not Level 1 Trauma, but they do have most every specialty, and one of the hospitals does site directed TPA for stroke. Seems like a good place to learn.

Drove across from Wisconsin via Chicago, Michigan is an empty state. Lots of flags at half mast, still, since I was there a month ago in Detroit, apparently this is because there are a lot of troops serving from Michigan who are quite young.