Day Off

It’s raining here. Which is better than snowing—only because I still haven’t winterized my swamp cooler. I keep planning on doing it, but just haven’t gotten around to figuring out when the neighbor is going to be home and I’m going to be awake so I can borrow his ladder and his porch. It’s the only way to get on our roofs. Anyway. I was going to be all motivated and get the oil changed in my car. But it’s raining. And I wanted to write on my blog. Which I initially planned to write in the lobby of the car place while they were changing the oil. That’s the handy thing about laptops; you can take them to the oil-changing place so you have things to do while their changing the oil. But it’s been raining all day and it’s my day off. So I find myself in a low oil changing state of motivation. And I’m ok with it. Maybe next week I’ll get the oil changed. And FOR SURE next week I’ll winterize the swamp cooler.
It’s recruiting time again for the residency program. Over the next few months all the fourth year medical students will be flying all over the country to interview at different programs. The exciting thing for me is that the program pays for dinner three nights a week at a pretty nice restaurant for the current residents (that’s me) and the interviewee’s (all those flying around med students). They want us to get to know them ‘in a relaxed and sociable atmosphere’. We’re supposed to try and impress them and tell them how great our program is. And we also get a chance to check them out and give a little input about whether or not we want them in the program.
I went to several of the dinners last year. It was pretty fun and pretty good food. There was one girl who I ended up sitting by sometime in January who left a lasting impression on me. I was trying to be very nice and talk to her about things—anything I could think of because she wasn’t very talkative. And I thought things were going along if not well at least ok. Later during the meal one of the other residents came down and started talking with her. He pointed out some of the people at the other end of the table and said how nice they were. Then she said, “Well, I guess I sat at the wrong end of the table.” Then later when they came around to ask if we wanted any dessert I told the waitress no, I was rather full. To which my little friend said, ‘Ya, you should be, I think you’ve eaten enough.’ Now I had not thought that I ate an exorbitant amount of food. I had a pita pocket sandwich and some French fries. Granted she did have a salad. But I really didn’t see the need for her little comment. Needless to say, she made poor impressions on other people in the program and it was agreed by all, including herself, that she would not be coming here for the rest of her training. Wherever she ended up, I hope she’s having a good time. And I’m glad she’s not here.
And now we’re on to the new recruits. I don’t know why I think it’s so fun to meet them. And then I get all excited for match day in March when we find out who’s going to be coming to our program. Even though I really can’t ever remember who I met or who I talked to.

Chocolate

I had no idea that there was such a thing as too much chocolate.

Grams was sleeping on the couch. She’s ninety. She takes a lot of naps. I’m not anywhere near ninety and I take almost as many naps as she does. She also goes to water aerobics three times a week. I do not go to water aerobics. Partly because of the beached-whale phenomenon that tends to occur when I’m in a swimsuit, and partly because I’m usually napping during aerobic time.

But today I was in charge of making the cookies. Normally Grams gets the Betty Crocker Chocolate Chip and Walnut cookie mix. Fairly fail safe, not too difficult. I don’t know why anyone would ruin perfectly good chocolate chip cookies by adding walnuts—but she’s ninety. She gets a lot of leeway for making it that far and still going to aerobics. But the store was out of the chocolate chip with walnut mix, so today she had only chocolate chip cookie mix. Sometimes life hands you warm chocolate chip cookies with out walnuts and you can only smile, get all gooey inside and wonder why you’re so lucky. And even luckier when it says “three hundred chocolate chips inside!!” on the outside of the mix.

Instead of a half cup of softened butter, Grams prefers Canola oil. “It’s better for you.” She says. And Grams does worry about our health. She also recently lost her measuring spoons so she got out a big mixing spoon and said to use that for the Tablespoon—‘it should be close’. And I’m sure it is.

So I added the egg and a half cup of Canola oil and mixed it all up and added the extra chocolate chips that we always add to ‘enhance’ the cookies a little. Who knew that a half cup of softened butter doesn’t convert right over to a half cup of Canola oil? They should really make that little star and the fine print a little larger on the back of the bag. I guess it should have been a clue when I didn’t need the Tablespoon. I thought maybe only the walnut cookie mix needed some extra ingredient that would use a Tablespoon. I thought it looked kind of funny—all the chocolate chips looked like they were greased up ready to shimmy into latex pants that were way too small. It was then that I read about how one half cup of softened butter could be substituted for a couple tablespoons of water and one third cup of Canola oil. Hmmm. Oh well, guess we’ll see how that works out.

Grams has a bulk bag of semi sweet chocolate chips for just these occasions. All her cookies are ‘enhanced’. Probably one day while she was at the gym she saw some body builder and realized that he was a little enhanced. Always one to look for positive things in the world she likely thought this was a great idea when applied to baking. Who knew that adding two and a half more cups of chocolate chips to the ‘three hundred chocolate chips inside’ would be a little much. Normally in the world of physics more chocolate is better. But after mixing up the batter and realizing that there wasn’t enough dough to hold all the chips together it occurred to me that perhaps there was a limit on amount of chocolate one cookie could support. But now they were all greased up with little bits of dough spattered through out. I had no choice but to bake them and see what happened. It was hard because a ‘spoonful of dough’ turned out to be a bunch of chips falling off the spoon that I tried to mush together on the cookie sheet. Hmmmm?….. with a furrowed brow…..

I have patients who do these kinds of things. They don’t read the directions on the bottles, and they don’t listen to me when we talk about their problems and I tell them ‘you need to go to the gym’. Why can’t they just follow directions? Apparently that’s what Rachel Ray would say to me. Follow the freaking directions!!

When Grams got up I was feeling a little self conscious about my baking abilities. “I’m a doctor Grandma, not a freakin’ chef!” --- right on the tip of my tongue ready to spout out when she asked why the cookies didn’t stick together. But she didn’t ask. Nor did she say anything when she picked one up and a bunch of the chips fell off and the whole thing just kind of fell apart at the chocolate chip fracture line. If left alone on the baking sheet they did resemble cookies. It was when you picked one up that the problems became apparent.

Oh well…. Grams didn’t take me up on my offer to make more cookies before I left from my little visit. She was probably thinking about that huge guy at the gym who’s neck muscles got so big that they smashed close his esophagus and he choked to death.

Sometimes too much enhancement can lead to real tragedy.

This has been a real eye opener for me. It may not be my neck muscles that are getting big, but I’m still in danger of having my esophagus smushed close.

Mmmmm.......

If you eat a whole chocolate cake, but you donate money to charity..... does that make it ok? I need to know before I go to Costco.

Bad Call Day

I just got up a little while ago after sleeping for fifteen and a half hours. Sometimes that happens after my 30 hour call shifts when I don’t get to sleep. And even after the fifteen or so hours of sleep I still feel tired. Thursday to Friday afternoon was my call shift. It was crazy. At about 2pm on Thursday the computer system went down for the VA hospitals. The regional system went down at the main frame….. what ever that means other than BAD, VERY BAD. Since EVERYTHING is on computers for the VA it makes it very hard to take care of people when the system is down. It was especially hard to admit people and get them the right medications and the right tests. The system came back up at about 10pm and then went down again at about 3am. It was a very frustrating call shift.

And one of my cute little patients died. He was a 59 year old guy who had terrible heart failure from ischemic cardiomyopathy (very enlarged heart because of lack of oxygen to the heart muscle—usually from a heart attack or something). His ejection fraction was about 18% (how much blood is pumped out of the left side of the heart with every heart beat, normal is about 65%). Because of his very poor heart function, several months ago they had put in a pace maker/defibrillator. He was actually doing pretty good at home. Very functional, up and about. He lived with his daughter and granddaughter. Went shopping, went for walks. Doing well.

He came in to the ER on Thursday morning because he was sitting on his recliner at home about to get dressed when he passed out. Then later during the morning it happened two more times. Other than that, he was feeling great. Good energy, happy.

In the ER they evaluated his pace maker. His heart had been going into a rhythm called V-tach (very bad rhythm where your heart doesn’t pump like it’s supposed to). His pacemaker was kicking in and trying to pace him out of it, but instead he was going into V-fib (even worse rhythm where you don’t really pump blood around at all and will die if you don’t come out of it with in a couple minutes) at which point he was passing out. Then the pacemaker would shock him and put him back in a normal rhythm. Normally we want the pacer to shock before someone goes into vfib and passes out. But it is a little nicer if someone isn’t awake when they get shocked. It hurts. But it’s safer than letting them pass out all the time.

So in the ER they adjusted his pacer settings and then decided that even though he was doing really well that they wanted to admit him to the hospital to put him on a new medication that would help prevent these funny rhythms. He was on a med for this called Mexelitine but it obviously wasn’t working.

When I saw him in the ER he was awake, alert and happy sitting on the end of his gurney, swinging his feet back and forth. He was in a talkative mood and I couldn’t stop him from telling me stories. He told me all about what had happened this morning and also all about his neighbors and his ‘adopted’ son who he could always count on. And about the guys down the street who were growing meth in the house and how he told his detective friend that there was something weird going on there—and they were arrested a couple days later. When I asked if he had noticed any fevers lately he told me about how his 5 year old granddaughter would bring him drinks and leave them on his night stand, but wouldn’t get too close because she had a cough right now. And he told me all about how he usually watched ‘Touched by an Angel’ and sometimes the show was good, but sometimes it wasn’t so good. But he liked it anyway.

So the arrhythmia guys decided to try Sotalol to help his heart. We gave him a dose of it in the ER before he came up to the floor. But then they called back and said they wanted to use Amiodarone instead of the Sotalol. We told them that he had already gotten the Sotalol and they said it was fine, just give him the Amio a little later.

A couple of hours later, the system still down, as I was trying to admit another patient and wishing I could rip out someone elses’ chest hair (not mine because I don’t have chest hair and if I did have chest hair I think it would hurt if it got ripped out) one of the nurses called me to tell me that my little guy had a low blood pressure and was feeling really dizzy and sick to his stomach. I gave him some IV fluids to help with his blood pressure. Just a little though, because of his heart. His blood pressure came up a little so we decided to start the Amio. Amio is usually given through the IV at first. First with a loading bolus and then then at a certain rate for 24 hours. Then we give it in the oral pill form. So we started the bolus. But his blood pressure dropped again. And he started feeling very sick to his stomach and like he couldn’t breath. Then he started feeling a lot of chest pressure. We stopped the bolus and the IV fluids and then called the ICU to have them come take a look at him.

Ten minutes later we moved him into the ICU because he looked so bad. And about twenty minutes after that he stopped breathing and lost his pulse. While one doctor did chest compressions and another put in central IV lines, I intubated him. We coded him for about two hours off and on. We’d get a heart beat back, but then lose it again. His family came in, and after a few discussions decided that this was not what he would want and so we let him go.

The hard part for me about him dying, was how good he was doing earlier. He wasn’t feeling sick at all. He was happy and didn’t really think he needed to come into the hospital. I couldn’t stop him from telling me all his stories. And then ten hours later he was dead.

We’re not sure why he crashed. But we have a couple of theories. His heart was obviously getting worse because he was having those bad rhythms. He may have had another massive heart attack while he was in the hospital. We also gave him new medication meant to prevent arrhythmias. But maybe his heart function was so bad that any more blocking medication was too much for his heart to work against.

We will never know exactly what caused his death. But I hope it was the first theory. I hope he had the heart attack and that he didn’t die because we gave him a new medication.

They tell me that someday I will directly cause the death of one of my patients. I already hate that day.

Wet Underwear Day

When I was in college we had to write a process paper. It was all about how something happened. Like how did you make a peanut butter sandwich, or how did you get straight A's in all your classes, or how did you get the toilet clean (not one single guy in our class picked that one). It had to show a step wise process. Cause and effect. And there had to be multiple steps involved.

Like today. But the process of today started last week. Saturday was my birthday (anyone who hasn't sent a gift is highly encouraged to do so) and I never do laundry on my birthday. It's not like a moral rule or anything. It just has never come up in all my......uh.....26 years or so. I only had to be at the hospital until around 2pm that day, and then I went and bought myself a really yummy chocolate cake at Costco. It's a really big cake though and while I was chatting with the woman standing behind me in the check out line she mentioned that it was also her birthday. And since it was a really big cake we decided to split it. The bakery was kind enough to cut it in half and give us another container. She told me all about her family and how her 17 year old daughter had recently decided she was a lesbian and thought cocaine was 'way cool' and needed a little whiskey shot to get going in the morning. She said girls were much harder to raise than boys.

And then I picked up a couple of friends from the airport and made it to dinner with the fam---just about an hour late.

Sunday I was on call at the hospital. Technically it's only supposed to be a 30 hour shift, but sometimes it oozes over a little. I left at about 1:30 on Monday afternoon. And I was lucky. It was a good call shift. I only admitted 4 patients to the hospital and I got to sleep for almost three hours. Not all at once, but cumulatively. Not too shabby.

Driving home from the hospital, I felt wide awake. Almost even energetic. Usually post call I take a shower and go right to sleep. But Monday I hung out with my new roomie Loni--who moved in almost 2 weeks ago, is really nice and has already done the dishes more times than Rochelle did during the whole six months she lived here. Because I was so 'energetic' I decided to go for a run and then remind my friends that really it was my 'birthday month' so I was going to need presents every day during April. But I got kind of cold, so I took a hot shower instead. And then I got tired. And instead of doing all the things I planned on, I hung out with my friends and then fell asleep at about 8:30.

Tuesday was a short call day. Which if I'm lucky means I get out of the hospital by about 4 or so. But I wasn't so lucky. I admitted a guy who has heart failure. His symptoms have been getting worse lately and he was actually seen in the ER three weeks ago. They fixed his meds and sent him home when he was feeling better. But he's got a little drinking problem and sometimes he doesn't have the best reasoning skills. It made him really nervous that he was having more symptoms so when he left the ER he thought the best thing to do would be to stop taking all of his medications and start drinking more alcohol. In Psychiatry this is called 'poor insight'.

I signed out to one of the other doctors around 5pm. At 5:02 I got paged by one of the nurses. 'Mr. ----- in room 2c02 had a critical lab result'. Critically low red blood count. Dangit. I left a couple of hours later than I planned.

At this point it was critical to get the laundry done. I started the most important load and then fell asleep reading a new book. My roommates woke me up an hour later and I was just coherent enough to turn over and tell them to put my clothes in the dryer.

Usually I get up around 5 in the morning so I can make it to the hospital on time by six o clock. I'm always on time. Or just a little late. Or a little more late. But I always blame that on the traffic. And since I fell asleep before I planned on it, I didn't turn on my alarm clock. So I was pretty bummed at 5:50am when I opened my eyes and looked at the clock. DANGIT. I ran down stairs to get my clothes, only to find them wet on top of the dryer. Not dry IN the dryer like I was hoping for. ON TOP of the dryer. I'm pretty sure I didn't say 'please put my wet clean clothes on top of the dryer for the night'. But I was sleeping, so maybe... If I'd been up on time I could have dried them. But I wasn't. And I didn't have a choice. It was a wet underwear day. Luckily for me it decided to be freezing cold outside again today so I got the full effect of wet underwear.

I got to leave the hospital by 2pm today, and they were completely dry by then.

I just put the rest of my clothes in the dryer. I'm on call again tomorrow and I don't think wet underwear will add happiness and sunshine to my call day.

I'm going to go eat some corn now.

This is for Chad.

I finished my national board exams yesterday. It was two eight hour sessions of testing. One session on Thursday, one on Friday. It will only take them 4-6 weeks to let me know if I passed or not (even though it's all computerized and it seems like I could just click 'END' and it could flash my score up on the screen. Perhaps they're worried about heart attacks or violent behavior if the scores weren't so great. This way you have plenty of time to almost forget that you're panicking about having to re-take boards before you get your score.)