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Saturday, April 10, 2004

Background Thinking 


There is a big difference between working an ED shift, and working a day of floor medicine/cards/surgery/ICU/PEDS. On the one hand, I go home at the end of my day, forget about everyone, and start anew the next day. On the other hand, while I'm working in the ED, I am working continuously. Literally. Pick up a chart, see the patient, order some labs/imaging, pick up the next chart, see that patient, order more labs, pick up a third chart, and a fourth chart. By this time, labs from the first patient may be back. Look at 'em, look at the x-rays. Make a decision and a disposition. Some patients will need interventions or procedures, which limits your ability to pick up the next chart, therefore your colleague picks up the next chart. Dinner? If I'm lucky, I can run over to the coffee shop for a snack. Staying hydrated? Forget about it. I've gone through entire 8 & 12 hour shifts without the need to urinate. Not that I can't find time, I just forget. Finding time to eat and drink feels selfish on a busy day.

The point of telling you this is...there is no time for my brain to mull over "background" thoughts and ideas. I'm sure everyone reading this blog has things they like to think about during the day. Projects, bills, friends, vacation planning, weekend planning, grocery list, etc. On floor medicine, you have downtime to let all these things run through your mind, but not while working in the ED. Every single moment is consumed by patient care and medical decision making. It's tiring!

As a result, when I get home, my brain not only needs to decompress from the activity of the ED, but also time to let these background thoughts that were supressed all day bubble to the surface. THe result? Three to four hours of almost manic, stream-of-conscious thinking, reading, internet surfing, project-finishing activity...very little of it medically related.

I'll talk more about background thinking later. In the meantime, check out Electric Sheep, a visual life form created by the background thinking of a global network of computers...concieved and designed by my high school friend, Scott Draves. See Spot Blog to drop in on his daily background thinking.

PS...I was too busy today to think about each patient as a visitor to my blog!

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Friday, April 09, 2004

Two Degrees of Blog...Resurrected! 

This resurrection may be 2 days early, but I'm resuming my weekly Friday blog meme...Two degrees of blog. Here's how it works. Pick a blog that you link to, and post a blog that they link to. Post both of them with a quick one liner of why you like them. Like this...

The Helix, an Australian medical studnet, links to This Won't Hurt a Bit, a medical student bringing interesting life experiences to his blog.

Blogborygmi, an med student blogging about science and technology, links to The Personal Genome, with an ironic (and impossible?) subtitie, "Genomics ... as a lifestyle choice," and a cool paisly background too.

Comment below if you're playing so we can see your new discoveries.

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Mr. Hassle website hits... 

I just looked at my monthly blog hits...they've risen every month since I started the blog last June 1st. Month one was about 100 visits, and last month was about 3000! If I continue to get 3000 hits per month, my yearly projection would be 36,000 visits per year, or the same number if visits that our ED gets! So next time I'm having a bad day in the ED and I find myself cringing with every "nurse to triage" call overhead, "ambulance in bound", or "physician to station one for medical command", I'll just envision someone new visiting my blog site with new patient we receive. If I can't make my patients happy, maybe at least I can make my visitors happy.
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Pain Day 

I was the pain clinic today in the ED. I think every single one of my patients that I saw today was in the ED because of pain. I didn't do much productive for any of them. Back pain, Tooth pain, Neck pain, Arm pain x 2 (one right, one left), scrotal pain. No one had any sympathy for my sciatic pain.

This morning I presented an M&M; and all went well with discussion and didactic presentation untiil the last 2 minutes when the department head asked the (non-rhetorical) question...could this have been prevented? Gulp. He thought yes, but all cases suffer from hindsight bias. How many patients get sent home and never get adequate follow up but never have catastrophic outcomes? Far, far more than the ones that show back up on a gurney, I'm sure. Anyway, that kind of ruined the rest of my day.

Then the radiologist and I had a little "discussion" regarding a testicular ultrasound ordered after hours. Does anyone know if there is a "re-torsion" rate after surgical correction? This teenager presented with what he described as the same symptoms he had when he had a torsion about a year ago. Given that I wanted to prevent another future M&M; conference, I decided to be a patient advocate and call in the ultrasound tech, even though he'd already had the surgery. Seeing as I have no personal experience with testicular pain, I had to believe what my patient was telling me.

During our radiology/emergency medicine monthly conference this morning, we discussed doing more pediatric ultrasounds as opposed to CTs for certain cases of belly pain. A point raised is that in our hospital, CT is available with techs in house 24 hours a day. Whereas the ultrasound techs go home at 4pm, and sometimes it's like pulling teeth to get them to come back in. I even had one radiologist tell me to "make something else up" as a reason for my study. "The tech won't think that's a good reason for an emergency ultrasound." I don't know why the radiologists let the techs dictate when studies are done, but part of our daily challenge is "ordering" tests that we think are clinically necessary, and not "requesting" tests that the radiologist or technicians don't think are necessary.

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Monday, April 05, 2004

Miscellaneous 

Now that Dr. Gene's '05 (?'04) is selling his own mugs on Blogborygmi, and Hermes is selling "Trust Me I'm Your Doctor" Thongs...I think that Doc Shazam needs some paraphanalia. I need a logo. Can anyone help?

Patients say funny things that I write down sometimes to provide a chuckle when I think I'll need it. Like the lady today who ended up in the ICU because she had to be "incubated" while in MRI. (She meant intubated).

Wish me luck on Step 3 of the USMLE tomorrow and wednesday. I talked to two people recently who *gasp* failed it! One of them called the USMLE to find out why and they said he got ZERO points for the entire second day of the test. If that doesn't sound like a computerized test taking glitch I don't know what does. Now I'm paranoid.

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Sunday, April 04, 2004

The Topology of Medical Thinking 

There are certainly more productive things I could be doing right now, seeing as I am taking Step 3 of the US Medical Liscensing Exam this coming week (a 2 day 8,000,000 question exam). But as my parents can attest, under times of academic stress, I frequently regress to more childish endeavors, such as drawing with colored pencils.

Still fascinated with uncovering the "standard of care" for diagnosing PEs, I decided to start with the well known Well's algorithm for evaluating risk, ordering tests and interpreting them. My goal was to create a process map ala the London Tube Map, to make a visually impacting impression on anyone trying to decide which test to order next. The difficulty is, that the order and meaning of the same test can vary depending on the results of previous tests or on the patient's condition.

I made three different diagrams last night before discovering that when trying to view the process as a network topology, it becomes a three dimentional process! No wonder it's so confusing. My goal is to make each lab test a singe node (e.g. D-dimer, VQ scan, CT angiogram, Venous duplex/follow up venous duplex (should they be the same node?).

Ultimately, if I can create noded diagrams for each algorithm, I could overlay them on one another to see where they differ and why. This whole process of trying to diagram scientific thinking somehow reminds me of a different type of mindful diagramming...check out GPS Drawing. And by removing the scientific thought from the process focusing only on layout and balance, the following pasttimes seem eerily related as well: Rock on, Rock on and House Gymnastics.

If anyone can help me figure out why my brain works this way, I would appreciate it.

Addendum: See also the four color graph theory (aka the four color map theory)

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Saturday, April 03, 2004

Seeking the Truth...the Naked Emperor 

Last night as I lay awake in bed, wired from the medrol dose-pack I'm taking for sciatic nerve inflammation due to raking gravel to fill in my driveway's mud and ice holes, I reviewed my folder of Pulmonary Embolism articles. I learned a few things. First, there is no single algorithm accepted as the standard of care for diagnosing PE except in the extreme cases (absolutely present, or absolutely absent). PE has been considered to both overdiagnosed AND underdiagnosed. How can this be the case? Joe Lex, a fantastic speaker and ER doc, has a great hyperlinked review of the history, controversies and current thinking on evaluating PE and why we can't yet diagnose such a potentially deadly disease.

In this review, he explicity describes no less than EIGHT different algorithms by many different authors in fields such as internal medicine, emergency medicine and radiology. He presents the strengths and weaknesses of the various studies as well as 10 different myths in evaluating patients for PE. I highly recommend that you review his article to stimulate your thinking about the field, and examine his extensive bibliography (partially annotated).

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Thursday, April 01, 2004

Whirlwind 

First day back in the ED in 2 months felt a little like my very first day in the ED. I forgot how to order lab tests, get x-rays, do a focused H&P;, smooth talk consultants...

But I did "fix" at least one person today. An unfortunate man with an infected knee and a "Peripherally Inserted Central Venous Catheter" for 6 weeks of home antibiotics. He came in because the arm that had the catheter in it was red & swollen. I sent him up to the vascular lab and sure enough, he had a clot in his subclavian artery. I called the coagulation clinic since I was working during the day shift, called the PICC team to put in a new catheter and got all of his followup arranged. He was a little bummed about the whole situation, but I was glad I found out what was wrong with him.

Later in the day, I argued with one of the medicine attendings about the use of the d-dimer test in patients with greater than a low pre-test probability for a pulmonary embolism. Then we argued about the definition of Low pre-test probability. He wanted to to add up points for the Well's criteria. I wanted to use my clinical judgement. Niether has been proven to be a better method, but he insisted I order the d-dimer anway when I already had an intermediate VQ scan. We then proceded to duplex his legs which were negative. So does he have a PE? Well, 30% of people with PEs have negative venous duplex exams. I'm anxious to find out what happened to him.

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Wednesday, March 31, 2004

It's My ... 

Last Day.
...of the ICU
...of inpatient medicine
...of rotations with overnight calls
...of sitting through 3 hours of trauma/critical care rounds, falling asleep in the dark
...of chasing interns orders


In celebration
my post from last year's last day in the ICU and my last day as an intern...

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