Vitum's Field Guide to Hospital Grunts - Patient Edition

1. HHUUUUUUUNNNNGGGGHHHH

ID: Reproductus cornicopious, the common multip (i.e. multiparous woman, who has delivered a few babies already)
HABITAT: Maternity Ward
ACTION REQUIRED: RUN AND DON GLOVES. She is about to pop.

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.

2. GAHHHHHHHHHH GAHHHHHH GAH GAH GAH GAH GAHHHH

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.

3. MMGGGGNNNNNHHHHHHHHHHH

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.

4. HUUNFGH

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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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."

Please, please, click this and even just read the first page of this cartoon...

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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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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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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.

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

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"...and that's when I broke the child's arm in my bare hands."

The surgery I was watching was getting into the tedious stages, fitting and re-fitting a bone chunk that cracked off when the elderly woman had slipped on a banana peel (yes, you read that right). They already had an assist, so I wasn't scrubbed in for this one. Just as I was looking for a new distraction the orthopedic surgeon's pager went off.


A five-year-old boy had fallen out of a tree, and landed on his arm, which was broken. The emerg doc was going to re-set the bone, but wanted the orthopedic surgeon to have a quick look at the x-ray first. They called it up on the computer screens in the OR, and the surgeon gave his blessing that the emerg doc could set the bone himself.


I asked the surgeon if I could go watch the reduction of the bone, and soon was on my way to the ER where I found the doctor. I knew him from working with him in the ER a few weeks prior.

"I heard you're doing a closed reduction - can I watch?" I asked.

"No," he replied.

I was a little surprised, but didn't have time to react before he said, "You're going to do it."

"Uh, I'll give it a shot, but just so you know, I haven't done one before," I admitted.

"That's fine, I hurt my wrist. Come look at the x-ray."

That's when things got exciting.

This wasn't just going to be a regular reduction.

The doc showed me on the x-ray where the wrist had broken through the smaller of the two arm bones, the ulna - but not quite all the way through the radius.

Turns out that for a break like this to heal correctly, rather than just pulling the bone into place, like is done with most reductions, it was important to make sure that the break went all the way through the radius.

And how would that happen?

You guessed it... breaking the radius would be my job.

Sure enough, after a quick briefing, under close supervision, and as soon as the child was COMPLETELY sedated (what, you thought we would do this with the poor kid awake?!), it was time to hold on to the arm just above the wrist, and see-saw it back and forth at 90 degrees until I heard a pop and crunch. And that moment was just as the doc had predicted: "That's when all the eyes of nurses and staff watching will bug out of their heads." Fortunately, the child's parents weren't there to see what was involved.

Once the bone was broken, we were able to tug it into position, and put a cast on while still applying traction with our hands, just long enough for the cast to harden. By then, the patient was just starting to wake up from the sedation.

And while the patient didn't remember a thing - thank goodness - I definitely won't forget doing this for the first time.

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Maybe I'm not cut out for this... maybe I should think about quitting...

This post was actually written around March, about 6 months into my third year.

I'll admit it. For a while there, in the middle of third year, I wasn't sure if this medicine thing was right for me. Just look at this line from a post I wrote back in January:

as hard as I am being worked right now, I'm doing what I love, and worked hard to be able to do.

Yeah, it sounds chipper and rosy, but in all honesty, I didn't actually say I enjoyed third year... I was really just trying to convince myself that I should enjoy what I'm doing.

At that point, third year was really starting to wear on me, and I was almost ready to throw in the towel. I try really hard not to complain, but I was ready to write a post similar to one of the many I have found on other medical blogs, featuring such depressing tidbits as: "Medicine has made me a shitty person" and "Times I muttered “kill me now” under my breath [during third year]: 84,239." (In fact, I found so many tidbits like this back in the day that I made a list).

There were a bunch of reasons I was feeling this way. A few: The shifts are so long. It's really hard to have a life while you're in med school. The finals are demoralizing, and you leave almost every one thinking you failed. It's embarassing when you feel like the custodian knows more about treating patients than you do. You have barely enough time to do your hospital work and call shifts, let alone study outside of them. You are in a huge amount of debt. You're on call whenever you want to be doing something fun with your friends. You keep making mistakes. The list goes on...and on.

But of all these, the biggest reason I wanted to quit:

I was sick and tired of feeling like I don't know anything at all.

Every day, I'd see patients and think I knew what was going on, and then realize I had no idea. Even if I knew what medical condition they had, I didn't know the basics on treatment - I mean the very basics - such as which IV fluid to run or if I should even start an IV, let alone how to treat the condition. Most of the doctors supervising me were nice about it, but I still felt like an idiot.

This is especially tough to handle when you have done two years of medical school, and worked your butt off to pass those exams, and feel like you have accomplished something by passing two years of medical school, completing a four-year degree before med school, and by even just making it into med school. But no. You show up on the wards, and then realize how very, very little you know.

Like I've said before, now I understand why some doctors are assholes.

I know I said I don't like to complain much, and actually, the only reason I am willing to vent about this is because I don't feel this way anymore. In fact, over the last month or two, I've come to a realization - I am actually enjoying what I'm doing.

Slowly but surely, the passion I had for all this - the same passion I felt back when I was a pre-med - is coming back.

I'm not sure exactly when it happened. It might have been when I did a full history and physical on a patient and then realized that I had learned a lot about those and could do a pretty decent one now. It might have been when I was chatting with an inquisitive nursing student who knew about as much as I did when I started third year, and realized that I've actually learned something this year. Most likely, though, it was when I thought I knew what was going on with a patient... and actually did get it right... and actually had an idea about what type of treatment they needed.

That's exactly it. After 4 years of high school, 4 years of undergrad, and 2.5 years of med school, I'm finally starting to be able to do what I've trained for for so long.

I'm finally starting to play doctor.

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PDA Update: Why I RETURNED the PDA I chose!

UPDATED Again June 24 - Now includes the phone I chose AND how I like it

In the summer I wrote a fairly comprehensive report on which PDA I chose for my clerkship, taking into account the pros and cons of the ones on the market.

In short, I ended up choosing the Samsung Jack (also known as the i616) from Rogers, known in the USA as the BlackJack II.

I LOVED this phone. So much. It was exactly what I wanted, and so much more.
I sent it back to Rogers today.

You see, Rogers came out with a new version of the Windows software - upgrading Windows Mobile 6.0 to 6.1. And that's when the problems began.

Why I returned it:

The old phone was fantastic. Quick to respond, looked great, worked amazingly well, good call quality, outstanding battery life, and ran all the medical software I used on a regular basis (post on this to come soon).

Then the new version of Windows Mobile came out, and it was horrible.

There were glitches that were merely minor annoyances, ie. waiting 7 seconds between songs in a playlist.

There were more severe annoyances, such as the phone randomly changing time zones, screwing up all your reminder and appointment times, or the battery life being significantly shorter with the new version of Windows.

There were major technological glitches, in that the phone would stop working - calls could connect incoming and outgoing, but would not have any audio. My internal medicine attending was not impressed when I missed his calls beacuse of that.

And then, to just drive me entirely up the wall, there were glitches that made me wonder if the people that designed it had ever used a phone before (switching the phone to "silent" silenced ONLY the ringers - but alarms, e-mails and texts would all cause the phone to ring loudly!)

Each one of these was a step backward - none of these problems occurred before I made the upgrade, which I downloaded from the cell service provider's website. And the improvements in the new version were minimal. So, I sent the phone back, and got a new one - which had the same new version of Windows - and ALL the same problems. And after a few months of not bening able to make calls, I finally threw in the towel and said "enough."

Which mobile phones I considered:

I looked at 3 phones:

• the HTC Touch Diamond, which my provider was willing to exchange for free


• Blackberry, which I would have had to pay for


• the iPhone, which I would have had to pay for

I had some qualms about the Blackberry and iPhone from the last time I went through this choosing a phone process, and the HTC Touch Diamond was new to me, but I reconsidered all of these.

Which phone I exchanged it for:

I was really excited about the HTC Touch Diamond. It's a sleek phone, with a Windows operating system like my old phone, so I knew it would support all the exact same software I had used. So, I went to a Rogers store and tried one of these slick things out.

After five minutes, the phone had just about finished booting up.

After ten minutes, the phone was about halfway through its mandatory First Startup configuration.

After fifteen minutes, I was trying to figure out how to do basic things, like start the Internet explorer, add a new contact, and use the keyboard.

After twenty minutes, I was STILL trying to figure out how to do those basic things, and was starting to get annoyed with the touch screen which was a tad unresponsive.

After twenty-five minutes, I was STILL doing the above, and just about ready to throw the phone against the wall. Learning to use a new phone should not be that difficult...especially for someone who is fairly tech-minded like myself.

After thirty minutes, I gave up. Scratch the HTC Touch Diamond off the list.

My concerns about the Blackberry and the iPhone were that not a lot of medical applications were made for these platforms - most are made for Palm or Windows.

However the medical applications I found I used almost exclusively were:

• Epocrates - a free drug lookup
  
• UpToDate - subscription to the latest research on medical topics (wait until your med class does a group order for a massive discount, or better yet, arrange one yourself)


• Archimedes - a free medical calculator


• Diagnosaurus - a free differential diagnosis generator

Even though I paid for Merck Manual, I found that with UpToDate on my phone, I turned to UpToDate for most topics.

Turns out all of the above except UpToDate are available as iPhone applications, and UpToDate is available through the iPhone, you just have to use the Internet connection. As well, Rogers offered me a deal on the iPhone.

So, I decided to set my concerns about the touch screen keyboard aside, and went for the iPhone.

The Verdict...How do I like the iPhone?

Perhaps the best way to answer this is to ask, what do I miss about the BlackJack?

Frankly, almost nothing. While I thought I would miss the tactile keyboard, it turns out that I'm getting along on the iPhone just fine. My typing is slower, mind you, but not by much.

As well, until the iPhone 3G S came out, the iPhone didn't have video. But to be honest, I never used the video on my BlackJack.

The only thing the BlackJack had the upper hand on was battery life - the iPhone isn't that great (no word yet on how much better the 3G S will be). As well, loading UpToDate on the BlackJack was faster - I didn't have to type in a password, because it was downloaded to the device already, rather than accessed through the mobile web.

The iPhone is much better at browsing the internet, or surfing through a long page on UpToDate, for example. Rather than rolling a little scroll wheel over and over, you simply slide your finger - much easier.

And, the iPhone's GPS is much faster to lock a signal than the BlackJack (even though both are extremely accurate) - helpful for finding hospitals or doctors' offices on the first day of a new rotation, and for using RunKeeper - a FREE program MUCH better than Nike's run tracker - to track my exercise.

All in all, I don't miss the BlackJack. But to be honest, I was perfectly happy with my BlackJack...before the new version of Windows. I'll even go so far as to say that had the Microsoft update not been so full of glitches, and I stayed with my BlackJack, I would be just as happy as I am today, as far as a medical device is concerned.

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Electives - any suggestions?

I'm currently looking into doing a two-week Emergency Medicine elective in any American city... any suggestions?

Most of the ones I've come across so far in my research are four-week electives, but we only get a two-week block during our third year at my school.

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The tragic outcome of a homeopath treating his daughter's eczema

It is devestating to hear stories of people deluded into believing that alternative medicine can cure ails.

It's even worse when the one who suffers never had a choice in the matter.

In England, a homeopath is on trial for gross criminal negligence after his daughter died of a skin infection. She could have easily been treated by a dermatologist, but instead, the father, a homeopath, provided only homeopathic treatment, the jury was told.

"The court heard that by the time Gloria was six months old, the eczema had begun weeping and her clothing and nappies would stick to her skin and tear it whenever her parents changed her.

"Crown prosecutor Mark Tedeschi QC said the baby girl's skin began to peel off, allowing infections to enter her bloodstream."

Her body couldn't handle the repeated infections, and she died from septicemia in May 2002.

Had homeopathy been explained to Gloria, I bet even she could have seen the folly of using mere diluted water to treat her raging skin condition and ensuing secondary infections...

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I sterilized a man today.

Sticks and stones may break my bones...

...but you better watch out, because I now know how to do a vasectomy.

Thanks to my nimble fingers, three men limped out of the urology office this morning, their virility forever compromised...at least we hope it is.

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First do no harm...unless you haven't gone to medical school

Albert was on the phone with his sister on a sunny afternoon last week, telling her about the trip they had gone on over the weekend and his wife's bingo winnings at the local senior's centre that week, when suddenly she interrupted. "Albert, don't be silly."

"What are you talking about?" he replied.

"Albert, I can't understand you, what's going on?" He was confused - he was speaking perfectly fine, as far as he could tell.

His wife walked into the room, and noticed that he was indeed slurring all his words, and rushed him to their naturopath. The naturopath saw his mouth drooping on one side, and told him he knew exactly what was going on. He promptly gave him a glass of water, into which she had mixed several spoonfuls of salt, and told him to drink up, and encouraged him to do this over the next several days. Why?

Because, as the wife explained to me, "Well, when the left side of the mouth droops, he has a deficiency of sodium. And when the right side droops, he is low in potassium, you see. When both droop, then he needs more calcium."

Sure enough, in about half an hour, his droop had resolved, and his speech returned to normal. So the naturopath was right, right?

Unfortunately, in this case, his naturopath was wrong. Because he'd had a heart attack in the past, and his heart muscle didn't contract the way it should anymore, giving salt to this patient was a bad decision. In fact, research shows that patients with heart failure have worsening of their symptoms when they have salt in their diet, and the most recent heart association guidelines recommend low-salt diets for these patients.

And why did he get better? It had nothing to do with chugging brine. He'd had a TIA, or a transient ischemic attack, exactly like a stroke except it's just that - transient. The brain is starved of oxygen for a short time because of low flow or a small clot blocking an artery, but then the flow is restored before brain tissue dies. Had this lasted long enough to kill the brain tissue, it would have been called a stroke; in his case, the symptoms - temporary paralysis of his facial nerve innervating the orbicularis oris muscle, causing a mouth droop on one side - went away about half an hour after he drank the salt water. Though it looked like the natural treatment worked, it in fact had nothing to do with his symptoms resolving.

But, because of this advice, his wife faithfully gave him several spoonfuls of salt every day, causing more and more water to build up in his blood vessels. And it wasn't long before his failing heart couldn't cope with this excess salt. He soon could walk shorter and shorter distances without having to stop for air, and would wake up gasping for breath in the middle of the night. His heart muscle's ability to pump blood, which had been measured right after his heart attack as still being still quite reasonable, couldn't cope with the extra water in his blood vessels and took a drastic turn for the worse.

I saw him when he came into the hospital with his wife, unable to breathe, but it was too late. Despite receiving massive amounts of diuretics, vasodilators, and being placed on a breathing machine, it was too little too late. A few weeks later his heart gave out completely, he died with his lungs full of water instead of air, with a look of panic on his face, gasping for oxygen, because of the misinformation the wife had been told naturopath.

It doesn't worry me that naturopaths provide a whole-person approach, and attempt to treat the cause of patients' ailments rather than the symptoms.

It does worry me when they cause harm to patients, and make their health worse.

Any doctor that prescribed salt to a patient with heart failure... not to mention miss the diagnosis of a stroke... could be sued, successfully, for malpractice.

It also worries me that out on the western coast of this country, in British Columbia, naturopaths have been given the right to prescribe medications,which not only seems to go against their entire profession's objective of treating things naturally, but is possibly dangerous given that they are quite simply not trained in this area.

But going back to the story...you know what the worst part is? Had he seen a physician earlier, this could have been avoided... but the wife didn't see it that way. She left the hospital, without her husband, thinking that traditional medical treatment had failed to save her husband, when in fact the damage had been done long before he got to the hospital. Hopefully, her stronger belief in natural therapy doesn't kill her too.

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That poor, poor transcriptionist. I almost admitted it was my first dictation.

I picked up the phone with a shaky hand, and slowly dialed the number for the hospital dictation system for the first time.

"Welcome to the Excelleris Express Dictation Service. Enter User ID , followed by the pound key," a cheerful voice said.

Good, I thought. She doesn't yet know that I have no clue what I'm doing.

I keyed in the number for the doctor who was dumb enough to ask me to dictate for him. 6-2-1-0-9-#.

Enter hospital ID. 1-6-#.

Enter work type. 1-0-#, specialist consultation of a patient.

Enter patient number. 2-1-6-2-7-8-1-#.

Beep beep. . . . beep beep. . . bee- okay, are you going to make me wait all day? this is where you start talking, idiot. Fortunately, it didn't actually say that to me.

I pressed 2 to begin, and slowly began to talk.

"This is Vitum Medicinus, M-e-d-i-c-i-n-u-s, medical student intern, dictating on behalf of Dr. Doe, a consultation note on patient James Smith, S-m-i-t-h, unit number 2162781, date of birth 02/20/1949. "

This isn't so bad, I thought. I picked up speed.

"Copy to Dr. Doe, copy to Dr. Wilson. Date of consult March 6 2009, date of dictation March 6 2009. New heading, patient identification. Mr. Smith is a previously healthy 60-year-old Caucasian male who presented to the emergency department with his wife and daughter. Period. New heading. Chief complaint. Open quote, I passed out in the McDonald's parking lot, close quote."

I was doing it just like all the doctors I had seen dictate before! I was dictating! How exciting! I went on.

"New heading. History of presenting illness. This afternoon Mr Smith was getting out of his car at McDonalds when he began to feel presyncopal, period, before he could stop himself he fell to the ground, period, he described his presyncopal symptoms as open quote I was light headed comma I felt like I was going to pass out, close quote, but denied vertiginous symptoms, period. he lost consciousness for approximately ten seconds and in this time did not have any tonic clonic movements comma nor did he lose control of his bowel or bladder or bite his tongue period."

Okay, it didn't go that smoothly. My actual transcription went something like this... or at least what it would have looked like if I hadn't known how to pause, rewind, and re-record:

"Uh.... um.... uh... consult...dictation.... on ... patient .... copy to... Dr.... heading...new heading.... History of, uh, no wait....go back... Mr. Smith..." ... well, you get the idea.

Starting to dictate on behalf of the physicians has been really helpful. I've done a fair bit since that first one, and the process has made me realize that as far as taking the history and presenting the physical exam goes, I've started to really get the hang of it. It's when it comes time to dictate the assessment of what the patient has going on, and the plan of how to treat them, that I kindof fall apart and realize that I still have a lot to learn; with my first dictation, I had a fair bit of trouble with it even though I had discussed the case with the doctor already. Obviously, that's what I'm here to learn in third year, and throughout residency.

After I finished my first dictation, I sat the phone down, and began to gather my notes. I took a deep breath in and out. I noticed that one of the other emerg docs had sat down at the same desk about two-thirds of the way through my dication, and turned to him and asked, "Do you remember your first dictation?"

He smiled really big, and laughed, as he replied, "I try not to!"

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Planning for my 4th year

"When are you going to be a doctor?" is a question I get asked by patients quite often.

I like to think they are asking because they are interested in my progress and eager to see me fulfilling my dreams.

More likely, however, the question is based on a thought process along the lines of:

"Is THIS GUY going to be a doctor soon!? He started out by asking me all these irrelevant questions - what's he thinking when he asks how many pillows I sleep with at night?* What's he going to ask next, what colour my blankets are?

Then... he moved on to a fumbling, shoddy excuse for a 'physical exam,' making sure he touched me in every part of my body. Why on earth is he "feeling for the pulses in my groin?" Is he making this stuff up? And now he is using his stethoscope 'down there,'** is he crazy?!...ohhhh dear, when is the real doctor going to show up??

Good heavens, how long until he is unleashed to practice his incompetence on me and my friends and family? I'd better ask so I can move out of town by then."

In my defense:

* This is how I ask about orthopnea, or increased difficulty breathing when you are laying down flat, a symptom suggestive of impending heart failure.

** I'm listening for bruits in the femoral artery, which could indicate arterial blockage or disease... and I always ask if its OK for me to proceed.

The answer to the question is, just under 1.5 years, and trust me, I'm even more frightened by the thought than you are.

More on fourth year...

As I get closer to graduating, however, a few more decisions need to be made. My classmates and I are at the point in our education where we are choosing what we want to do for our fourth year.

While our first two years were mostly lectures, and the third and fourth year are mostly clinical, the third and fourth years are quite different.

Our schedule is quite firmly set in third year - we rotate through a number of "core" specialties (internal medicine, pediatrics, surgery, obstetrics, etc), and the only thing we can have any input on is the order in which we do these (and even still, need to enter a lottery to decide which students get to pick first).

However, in fourth year, we have a huge amount of flexibility in that we choose a number of electives. These can take place anywhere in Canada, the USA, or in some cases, elsewhere in the world, as long as I meet the requirements for the individual programs (some American schools, for example, want you to take the US Medical Licensing Exam after my 2nd year of medical school, which is not required in Canada).

The dirty details (for those who care...or can offer me some help!)

Based on how I understand it, what a medical student chooses for their senior electives is prompted by a number of factors, such as -

• the requirements of their school - I have to do at least 1 elective in each of the following: medical, surgical, primary care

• the career and residency programs they are interested in - someone interested in Plastic Surgery will obviously want to do many electives in the same, and check out the cities and hospitals where they might do their training

• geographic preference - a specific city might be chosen for an elective because they have a good residency program the student wants to check out, or because the student can easily arrange accomodation there with family / friends (it helps to avoid paying double the rent for the months you're away!), or simply because the student wants to visit a city they've never been to (my friend did a 3rd year elective in Pittsburgh so he could go watch a Penguins NHL game)

• interest - a student applying to a generalist (i.e. Family Practice) or less competitive specialty will probably spend more of their electives experiencing a variety of specialties they find enjoyable and interesting, rather than ones they think they "need" in order for their application to be impressive

As well, I also need to consider some other things regarding when I do an elective, based on applying to residencies:

• whether or not the elective has a lot of call - if so, it might be tough to work on an application for residency at the same time!

• whether or not it's likely to yield a good reference letter for residency - this only applies to the first few electives until the reference letter due date - you're more likely to earn a good reference letter from a specialty in which you work with 1 preceptor quite often, rather than something like emergency medicine, where you are supervised by someone else every shift.

Here's what I'm thinking so far, given that I am mostly interested in emergency medicine but may apply for a family medicine residency so that I can have a variety of options when I finish (ie. spend my time delivering babies, working as a hospitalist, or doing surgical assisting):

• Places - I'm thinking of doing my electives mostly in Alberta, BC and Ontario, because that's where I'm thinking of doing my residency, they're most familiar to me, and I know more students who have done electives in these places and therefore can get the scoop on them

• Basics - I'm interested in spending time in ER and obstetrics, so I'll likely do at least 1 elective in each of those

• Helpful add-ons - For someone interested in ER, I would probably benefit from spending some time in pediatric emergency, trauma surgery, and/or anaesthesia

• Just for fun / interest - If I have time, I might as well do some shorter electives in things I don't know much about, that intimidate me, or that I have simply never seen - such as rheumatology, or neurology

There are a few deadlines for choosing coming up, so now, the question is to decide where I want to do each of these electives, and if there's anything I'm missing. If you can think of anything, by all means, let me know!

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Trauma Team vs. Delirium team?

My Internal Medicine attending made an interesting point today, brought up at a lecture by Dr Rivers (famous for his work on treatment of shock/sepsis in the emergency department, published in the NEJM):

• Number of hospital staff who work on a trauma patient who just arrived at a large hospital: usually ~10-20


• Your chance of dying from an auto accident if you make it to the hospital alive: ~10%

• Number of hospital staff who work on a patient with delirium who just arrived at a large hospital: perhaps the medical student at first, then the doctor when s/he gets around to it


• Your chance of dying from delirium: ~50%

A bit of a disconnect, perhaps?

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Internal Medicine so far

I'm well into my Internal Medicine rotation. Fortunately, I have been well-warned that internal medicine attendings are notorius for demanding perfection, immense detail, and will respond to any lack of the aforementioned with insults substantial in volume and quantity, so it wasn't too much of a surprise.

Here are a few choice events so far:

• doing CPR for the second time (second time for real, that is) in a code blue

• one time feeling like I had learned something about medicine

• most times feeling like I have not learned anything

• being schooled by nurses who know critical care medicine much better than I do

• being asked by my attending doctor, "I was wondering when your brain would turn on" (don't worry, he was joking...I think)

• developing near-delirium after losing my cell phone in a call room (the first time I have ever lost my phone in about 5 years)

• smelling fetor hepaticus - the "sweet, feculent odour" on the breath of a patient with end-stage liver failure

I haven't cried yet, so I think that means I'm doing well.

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Drinking from the fire hydrant

My facebook status this week:

Vitum is entering one of those hell weeks that usually end with his friends asking, "Why don't we see you anymore?" Trust me, my bed feels the same way.

I spent most of Christmas describing third year to my friends and family like this: it's like working full-time (a doctor's definition of full-time, which is often 50 or 60 hours a week), plus being on call for an overnight shift every fourth night, plus studying for a major exam every month. Wheeeee!

Like I've said many times before, though, I am careful not to whine too much. Not only were my first two years of med school two of the most fun-packed years of my life (as I was reminiscing with a classmate just this afternoon), but as hard as I am being worked right now I'm doing what I love, and worked hard to be able to do.

After all, it is indeed my signature at the bottom of the application to medical school from three years back.

Yet, sometimes I check just to make sure.

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The strangest thing said to me during a pelvic exam

She had been fairly relaxed about the whole situation, considering, and after taking her history and doing the rest of the physical examination, I was standing at the foot of the bed. She had assumed the unpleasant position, and I was cautiously brandishing the well-lubricated speculum, when she said to me,

Don't lose your gum, Vitum!

Hope I didn't look that eager...

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