Saturday, December 19, 2009

Vitum's Field Guide to Hospital Grunts - Patient Edition


ID: Reproductus cornicopious, the common multip (i.e. multiparous woman, who has delivered a few babies already)
HABITAT: Maternity Ward

BACKGROUND: There is a saying on the maternity ward: “Never turn your back on a multip.” It is a known medical phenomenon these women, who have already had a few babies, have shorter and shorter labour for subsequent pregnancies, to the point where you better not ever be too far away or you’ll be picking baby up off the floor.

I have actually been trained that these multips often make a loud, primal, guttural grown the moment before the serious pushing begins. If you’re not in the room, and you hear this, hustle.


ID: Narcoticus demandilus, the drug seeker
HABITAT: Emergency Department
ACTION REQUIRED: Holistic support up to and not including writing an opioid prescription

BACKGROUND: The loudest patients demanding pain medication tend to be the ones for whom Tylenol just doesn’t work, they’re allergic to the stronger anti-inflammatories, and gosh darn it your only option is to prescribe the good stuff. The ones who are bad at it are the ones who only seem to be in pain when the doctor walks by, and are easily fooled (i.e. “Let me examine your back.” “Ow ow ow! Even the slightest touch on my back hurts!” “Funny, when I felt your back earlier and didn’t warn you that I was examining you, you didn’t seem to notice…”
A good rule of thumb is the more convincing the patient, the more you should look for signs they’re trying to fool you.

Be careful, though. Every so often you’ll get someone who you are convinced just wants drugs, and then you are later corrected and find out with convincing evidence they are in legitimate pain. Looking back and realizing you denied a cancer patient some form of relief makes you feel really bad.

The hard part is, there is a legitimate argument that drug seekers need treatment too, just not the drugs they’re looking for. This is something I wish modern medicine could treat way better than it does.


ID: Constipationaticus fecalis, the bunged-up ones
HABITAT: Old folk’s wards
ACTION REQUIRED: Grab a diaper. Just in case.

BACKGROUND: I was called one night to see an ornery elderly woman, and recognized her from seeing her in the emergency department, shouting at the nurse. “Closer, I’m deaf! Closer! Louder! I can’t hear you! Closer! WHY ARE YOU SHOUTING AT ME? *smacks the nurse*” I thought she was hysterical.

I’m not even sure what the original call was about, probably needing a sleeping pill or something basic like that. All I do remember is walking in the room, and she was moaning, as above. “MMGGGGNNNNHHH!”

“Why are you groaning?” I asked of the woman laying in the bed, gripping the siderail for dear life. “I’m POOPING!” she shouted at me. “I’m POOping in my DIAper!”

I was only a third-year medical student at the time, so not an expert in things medical. But I did know a few things, and took haste to correct her.
“Ma’am, you’re not wearing a diaper.”

The ruckus stopped. She looked down, and stopped to think for a minute.

“MMGGGGNNNNHHH!” I went and got someone who knew where the diapers were.


ID: Cardiovascularis joltishockus, or defibrillating a semi-sedated patient
HABITAT: Emergency department, cardiology ward
ACTION REQUIRED: Increase sedation!

BACKGROUND: Some patients who have a heart arrhythmia need to be shocked with the defibrillator, or cardioverted, to get their hearts back in normal rhythm. They are given sedation, then, under strangely close supervision, the medical student is often allowed to push the button with the little lightning bolt on it. One or two, sometimes three, shocks, and their hearts are back to happy beat (Yes, that’s what we call it when the patients are sedated and can’t hear us).

There was one patient who didn’t seem to have very much sedation. He had just barely fallen asleep, and the doctor turned to me and said, “Vitum, push the button!” “Uh, does he need some more propofol?” I asked. “No! Push the button!” So I pushed it, wincing a bit as I did, sending 100 joules of electricity through this young, muscular man’s heart.

The machine clicked, the patient jolted just like on TV, uttering a HUUNFGH, and his eyes went COMPLETELY wide open. And he turned his head, and stared directly at me. And stared. And stared. His eyes were bugging out of his head, and he was clearly sending the first silent death threat I had ever received, probably trying to kill me with his mind.

And then the doctor said the words I didn’t want to hear: “Hmm, he needs another one. Shock him again, Vitum.”

I asked the patient later if he remembered. Fortunately, the doc was right – he’d had enough sedation, which made me breathe a huge sigh of relief. I swore he’d be waiting in the parking lot for me after work.

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Wednesday, September 23, 2009

Few things are worth more than sleep...

...and telling you about this cartoon is one of them.

"Sufferers of schizophrenia are no more dangerous than anyone else."

Medical school has taught me an immense amount about the reality of mental illness.... and this cartoon can teach you the most important things I learned about it, in only about a minute.

"If I'd had cancer, people would have rallied around, but because I had schizophrenia, few wanted to know."

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Wednesday, August 19, 2009

The best part of spending two weeks with medevac? Not what you might think.

As my third year was winding down last month, I had the opportunity to do a two-week elective in anything I wanted. Supposedly it had to be medically-related, but given that some of my classmates were approved for two weeks of wakeboarding or a 3-hour first aid course*, spending two weeks in paramedicine made me look like an overachiever.

The elective was pretty incredible from a medical point of view. Among the dozens of calls we attended, we picked up a young lady whose ATV had gotten away from her, crushing her leg to the point where she might never walk again. We also treated a few patients who had fallen off ladders or nearly drowned, and a nailgun injury. As well, there was a variety of medical patients too complex for the rural hospitals who needed to be brought to the big city for super-specialized care.

There were things that I didn't anticipate. There were heart-wrenching moments, like talking to one of our patients, a young lady who had been poisioned by carbon monoxide...intentionally. Sadly, she was not the only suicide survivor that we saw during my two weeks. As well, we went to a few car accident scenes and I saw some things, tragic things, that I wish I hadn't.

One thing about the elective really surprised me. Those of you who have read this blog for a while might remember that I have shadowed flight paramedics in the past. Back then, it was fascinating for me to see what the paramedics did...treat and transport the sickest patients in the province. What surprised me is that this year, my time with the paramedics served as a stunning eye-opener, revealing to me how little I knew about not only paramedicine, but medicine in general back then.

In other words, until I had completed my third year of medical school, I had no comprehension of just how sick the patients were that we were transporting. Not only that, but I had no idea the elite level of training of the flight paramedics. Back then, I did not understand the skill demanded when handling ventilator settings for patients with severe lung disease, or the implications and specialization required in order to keep alive a patient with bacterial infection coursing through their entire body. I only now realized just how sick these patients were, having been involved in identifying and treating sick patients myself, and also that some of the drugs that the paramedics were trained to prescribe are typically only used by intensive care specialists.

It was exciting to be able to understand at a deeper level the diseases affecting our patients, and to be able to have a new level of conversation with the flight paramedics, actually discussing treatment options with them. To put it another way, before I had completed three years of medical school, I didn't even know what questions to ask.

Needless to say, my understanding of the complexity of the patients and the difficulty of their management gave me a new level of respect for the critical care flight paramedics.

Retrospect, for me, is a valuable, meaningful experience. In fact, one of the reasons I started this blog was so I could look back and see how far I've come; in a program that is years in length and where you rarely realize how much you have learned from day to day, sometimes looking back is the only time you'll realize how much you are learning. It was a huge privilege to be invited back to spend time with these highly-trained paramedics, and it was a great surprise to discover that without realizing it, I had signed up for two weeks of seeing how much I have learned. Glad the $45,000 I've spent so far on tuition seems to be paying for something!

*In defense of my classmates, they did have to write a 500-word essay relating their elective to medicine

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Saturday, August 15, 2009

Part 2: Vitum Loses 85 Pounds...and the mistakes that kept me from doing it earlier

Continued from Never Trust a Skinny Chef. A Fat Doctor, however...

For several years, I was eating healthy, knew about the dangers of obesity, and yet found myself at 280 pounds... so overweight that I was considered class 2 obese. So why wasn't I losing weight?

There are three reasons - three mistakes I was making. Once I corrected these mistakes, and took on a lifestyle of a healthy, balanced diet and exercise, the results were amazing:

  • In September, I weighed 280 pounds. By January, I was down to 230 - I had lost 50 pounds.
  • In April, I met my long-term goal of running a 10 kilometer race, something I thought was a big deal
  • In May, I blew that goal away - and successfully completed a half marathon. That's right, I ran for 21.1 kilometers. Never thought I'd pull that off. Ever.
  • My weight now is 195 pounds. That's 85 pounds lost so far (I say so far because that puts me - believe it or not - still at an overweight BMI. 10 pounds to go.)
  • Finally, I don't feel like a chump telling patients they need to lose weight to be healthy... and in fact, if I want to show them it can be done, I just point to the photo of me on my ID badge from September.

So, what were those mistakes that kept me from doing this earlier? Well, for three easy payments of $9.99 sent to.... just kidding! Here they are:

1. I thought QUALITY was more important than QUANTITY.

Healthy eating is important for disease prevention - I ate multigrain bagels and chose sugar-free fruit juice for years, never buying pop, chips, donuts or cookies... and only gained weight.

Consider this: I would go to Tim Horton's for a snack between morning classes and proudly ate a healthy 12 grain bagel with cream cheese, instead of what I really wanted - a chocolate glazed donut. Despite my choice being overall more healthy, I was eating 471 calories of healthy goodness instead of the 260 calories in the donut - almost DOUBLE! If I ate one of those bagels every day, and didn't jog for half an hour to burn off those extra 471 calories, I would gain almost 50...that's right, FIFTY... extra pounds in a year.

So, I changed my mindset to cut down on how much food I ate, instead of just choosing healthy foods. And wouldn't you know it, the pounds started coming off. That's why I like to tell people I started on the "put less stuff in me diet."

2. I used to only think of my weight when I stepped on a scale.

In order to actually make a difference and lose weight, my goal to lose weight had to become something I thought of every minute of every day, not just for the moment when I stepped on a scale in the morning.

I knew you had to eat less to lose weight, but I always found myself only thinking about this between meals, and forgetting about it when the food was in front of me.

So what had to change? Every decision I made, such as getting in the elevator, and every time I put something in my mouth, such as my morning coffee or cereal, had to be filtered through the perspective of "how could I change this to increase calories burned or decrease calories taken in?" The answers were easy - take the stairs instead, switch to milk in my coffee, only 1 bowl of cereal instead of 2 (okay, who am I kidding, 3). I just had to ask myself the question...dozens of times in a day, before I did anything.

My weight loss goals had to be something that influenced everything I did and every thought I had. Sure, it might sound a bit obsessive, but after years of unsuccessfuly trying to "eat healthy," for me, that's what it took - a complete mindset change.

3. I didn't use a simple strategy to overcome my hatred of exercise.

I hate exercising. I was able to run regularly for a while a few years ago, but that dropped off. I didn't really have anything to keep me going.

But now I found three things to keep me getting out there and exercising. First, I combined exercise with diet modification - and started to see results. Seeing the weight come off, and having people comment on it, is a great way to keep you excited about getting out and running.

Secondly, I began to time myself, and try to break my records. I got RunKeeper, a free app for my iPhone, and tracked how long it took me to run a certain time. The next time, I would try to run the same distance just a second or two faster.

Thirdly, I signed up for a 10k race. This gave me a goal to work towards, and an exciting event to participate in when the day finally came.

Now I just have to come up with a way to overcome my even more intense hatred of lifting weights...

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Monday, August 10, 2009

Never trust a skinny chef. A fat doctor, however...

U.S. President Obama with Dr . Benjamin, Surgeon General nominee. Source: The White House

Today's LA Times has an interesting piece about a new Surgeon General nominee in the USA, who herself is obese. Her nomination has generated discussion about whether or not doctors should be overweight.

Let me explain why this article caught my eye.

Last year, in a family practice rotation, I was in the room when my preceptor was counselling a patient on theimportance of losing weight to cut down his risk of heart and stroke (and countless other diseases). The patient was obviously feeling a bit sheepish about the lecture, and awkwardly tried to draw the attention away from his waistline. He pointed at me, and said, "Well, this guy will be needing to lose some weight too then, won't he?"

This was the first time somebody had said something about my weight since I was teased in high school, and afterwards, my preceptor apologized profusely for the behaviour of his patient. However, even though it was a bit more surprising and amusing to me than offensive, he did have a point.

At that point, I was 6' and weighed almost 280 lbs. That means my BMI was 38.0 - not just obese, but class 2 obese... and my disease risk for high blood pressure, heart disease, and type 2 diabetes was a few pounds short of extremely high.

If you think this is starting to read like a diet book, it actually does. I had always "eaten healthy," and had even done some jogging in the past. My list of reasons to lose weight was long...pages long. But not long enough to get me to have a healthy weight.

At the start of third year, my list of reasons to lose weight got longer. I began to spend over 8 hours a day seeing patients....most of whom were fat, and most of whom were dying or very sick... because they were fat.

In fact, every ward I rotated on showed me new ways people were suffering from obesity. I expected to see fat people with heart attacks on the cardiology wards, but I began to see obesity-related diseases and complications in ALL of my other rotations, almost ENTIRELY due to the patients' obesity, in other words, PREVENTABLE - in orthopedics, ophthalmology, surgery, maternity, emergency, dermatology, anesthesia, and scarily enough, even in pediatrics.

I knew that obesity caused disease, but that didn't really frighten me. Until I saw the complications of the diseases first-hand. They can lead to heart failure (which is a slow death with fluid in your lungs just like drowning), heart attack (pain and sudden death), stroke (paralysis and loss of ability to speak), dementia (to the nursing home we go, and hand in your driver's licence and memories of your family and friends on the way), permanent loss of sensation (can't tell if you stepped on a tack, so it could stay in your foot for WEEKS until you notice - yes I have seen this happen), osteoarthritis (waking up with pain in your knees every single morning increasing until you can't walk anymore), limb amputation (I have seen black toes and feet from the arteries getting so clogged with fat that they stop supplying blood to the feet) and blindness (a complication of diabetes). All because of obesity...all almost entirely preventable.

Seeing all this helped me get my butt in gear. I took a close look at my lifestyle and eating habits, and was surprised to find some mistakes that I was making. That's right - I discovered that even as a reasonably bright, educated medical student, there were simple things staring me right in the face, easy things to change in order to lose weight, that I was oblivious to (I'll talk about these in another post shortly).

And soon, I began to see results. Dramatic results. I've lost so much weight that people barely recognize me anymore.

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