This time last year: Nicaragua, Leon’s ancient stone cathedrals with bullet holes, joyful children with firecrackers in the street, large papier mache puppets, a beautiful young man swimming in the empty Pacific, we are gliding through tropical waters, sitting and sweating on sacks of grain on converted school buses, sobbing, sobbing, sobbing, laughing
Resolutions last year: Improve posture, eat more lentil mush, survive school
Month 4: turned in a thesis. Declared a master of science. Passed my first medical licensing exam.
2 months of surgery, touch my first pancreas, see my first brain, place my first suture, run my first trauma
Watched a man die. And be brought to life again. And die again.
8 months of no breath and ascending madness.
Accrued frozen pictures:
(1) Code blue in the cath lab, a frenzied tableau framed in the window. The lone cardiologist quietly exits, drops his mask in the dark, curses softly. His wire punctured her heart. On the x-ray screen there is the dying woman’s rib cage, and the delicate bones of the intern’s hand pumping rhythmically. On the machine, all the bones are the same.
(2) The sun rise in the ICU
(3) The neurosurgeon’s precisely placed bolt in the doll faced toddler, 10 physicians and nurses crowded in the room staring intently at the ICP monitor, the wrong line, the wrong wave, the numbers incompatible with brain life, the machines still breathe, his cheeks are still pink.
(4) The labor suite had 9 women: the single new mother, her own mother, the ob-gyn residents, the students, the nurses, they strained against her body, like the soldiers in the famous photo—the soldiers of Iwo Jima, the women giving birth. The room was too warm, thick with everyone’s sweat, smelled of blood and shit. We are women too, the pediatric resident and me. We greet the only male in the room, a small wriggling gray thing amid the women, the blood and the shit.
1 more year of San Francisco, the warm glow of the city by the sea, now a maze of obstacles: a place to park, the bus to catch, shouting madmen to avoid, the young and carefree to resent.
A year to be weary of what is to come. A year to revel in the things I have seen.
2 years seeing the beautiful young man, who endures my madness, who fills me with light.
Bowls of lentil mush consumed: 1.6
Resolutions next year: Survive school. Nurture mental health. Build strength, build skill. Stop whining. Love the boy. Love the tribe. Buy fewer lattes.
Thursday, December 31, 2009
Wednesday, December 30, 2009
The Final Manifesto
by Joshua Mehigan
1. We see you.
2. We know who you are.
3. Your ideas are worthless.
4. Your aesthetic is stupid.
5. Your “technique” is a welter of narcissism, superstition, and habit.
6. All your little tiny ideas, all your whoring attempts at creation, and you yourself are nothing, nobody wants you, we despise you, it’s in our nature.
7. You should be kept as a pet.
8. You are a Philistine, the Paul Bunyan of decadence, an acromegalic fraud.
9. You are a minnow, a speck, a stain.
10. The genre humain is sick, and you are to blame.
11. You are a necrophiliac.
12. You are a museum of irrelevance.
13. It will take years to make Art vital and important again.
14. You are from this moment forbidden.
15. As the Italians say, Parla quando piscia la gallina.
16. We are here now.
17. Our aesthetics is empirically grounded.
18. Our taste will be raised to principle.
19. You and your band of jays will be flushed out.
20. Yes, Art is resurrected today: Victory is ours!
21. History will forget you and salute us.
22. Here you are, and here is oblivion.
23. This is the final manifesto, and the only one.
1. We see you.
2. We know who you are.
3. Your ideas are worthless.
4. Your aesthetic is stupid.
5. Your “technique” is a welter of narcissism, superstition, and habit.
6. All your little tiny ideas, all your whoring attempts at creation, and you yourself are nothing, nobody wants you, we despise you, it’s in our nature.
7. You should be kept as a pet.
8. You are a Philistine, the Paul Bunyan of decadence, an acromegalic fraud.
9. You are a minnow, a speck, a stain.
10. The genre humain is sick, and you are to blame.
11. You are a necrophiliac.
12. You are a museum of irrelevance.
13. It will take years to make Art vital and important again.
14. You are from this moment forbidden.
15. As the Italians say, Parla quando piscia la gallina.
16. We are here now.
17. Our aesthetics is empirically grounded.
18. Our taste will be raised to principle.
19. You and your band of jays will be flushed out.
20. Yes, Art is resurrected today: Victory is ours!
21. History will forget you and salute us.
22. Here you are, and here is oblivion.
23. This is the final manifesto, and the only one.
Wednesday, December 23, 2009
Judgement
i am a smart geek, a guy this author wants to sleep with, a person who loves excess verbiage, confirmed 90s literati, someone who can start a fire. A liar. A drinker of scotch, good at crosswords, a girl who keeps a journal, a conspiracy theorist, (bigger than even the orwellian), a person who has read only one book my my life and it was to kill a mocking bird (and it was assigned reading in the 9th grade); a girl who loves guys in skinny jeans, a man who owns a cottage (one with an adjustable rate mortgage), a man who uses the words 'dubious' and 'tenacity'. I am that kid in your philosophy class with stupid tattoos, i am a premature ejaculator. I moved to Thailand after high school for the drug scene, I can quote the comic guy from the Simpsons I am a youth group leader that picked my nose in the 4th grade, a girl who cannot spell "leheim", who bought the first generation Amazon Kindle, i turned vegan to cover up my eating disorder, i played Creep while smoking pot and having sex, and I took care of my dying grandparents. Some of these are lies, some are not.
You too can stereotype people by their favorite author: Readers by Author
You too can stereotype people by their favorite author: Readers by Author
Wednesday, October 28, 2009
Fantasy Receptionist
My favorite television shows now are Mad Men and The Office (if you consider the Daily Show in its own category). These are both good shows and nicely made and obviously someone put lots of talent and work into making these so very lovely. But I suppose some amount of my ravenous consumptions of these fantasy worlds—one in which everyone is elegantly fashionable and self assured in their discontent and racism/sexism and the other in which everyone is exquisitely absurd and thoroughly bathed in the light of pitch perfect witticism—is my fantasy to be a receptionist.
In this other life, I am a very happy secretary/receptionist/personal assistant. I bathe not to make up for lost hours of sleep but so I may smell fresh and brighten the office. I wear heals. Rather than scrubs and awkward ratty student white coats I wear clothing that comes with a waistline. I have a bee hive and in this fantasy world, I wear long bright red false nails not outlawed by the CDC. They only mildly hinder my typing speed and make a pleasant clackety tip tap noise.
As a receptionist, I am hot. This is helped by the fact that I don’t have to arrive anywhere at 530 am. Nor do years of cortisol overload lead to peculiar weight distributions, terrible skin, and a diet consisting of vending machine products. I don’t worry about getting sued if my cleavage shows, and I don’t have to worry about offending people by putting my boobs in their face while I examine their ear wax and nose hairs. This is because I will not be examining their ear wax and nose hairs. I can wear short skirts and offensively ugly earings that will not get caught in my stethescope. I will not have a stethescope.
Instead of 2 years of pre med, 4 years of medical school, 4 years of residency required for training, not to mention the additional 2-6 years spent discovering genes, reconstructing the health systems of small nations, and dicking around to salvage one’s mental health, I can get pretty good at a particular office space in less than 1 year. I can already type very well you see. My handwriting is very good. And I am excellent at filing, especially when stoned.
At 5 pm, I depart and arrive at my single young woman urban apartment, and I kick off my heals and lounge on a luxurious piece of furniture which I have purchased with my single young working woman salary (which is actually a positive rather than a negative number). I sensuously pet my cat and speak in a deep throaty voice to this creature of my day’s adventures. I am allergic to cats, but in this other life I may as well eliminate other burdensome details of this one.
A girl friend calls, shall we get cocktails and pick up handsome men, and I will say no dahling I must finish my novel tonight. I make dinner or someone makes it for me, and it has real vegetables in it. I drink an after dinner brandy, since in this other life I am mentally healthy and I do not worry about a single drink dissolving my threadbare semblance of sanity and wildly sobbing for the next several days. I type. In my underwear. What the hell, I am so mentally robust I have a beer. I have 2. I smoke a cigarette, which in this other life is sexy and not so bad for you and does not prompt me like a little seal into reciting cardiovascular outcome statistics and mortality rates for small cell lung carcinoma. I fall asleep in soft sheets.
On the weekends I attend a vigorous pilates class, followed by a bloody mary. Followed by another one. I sit around in my underwear some more, typing, scratching my belly, smoking drinking napping. I have a boyfriend and he is actually something I have kept from this life. I call him poopsie, but in the other life he permits this. We have a wild and exotic love life and frequently fly to tropical islands
Of course, in this other life, I would not be a particularly good secretary, as the same things that offend me about being a medical student would persist: being bossed around. Detail orientation. Doing meaningless work. I would forget things. I would stare away into space. And it is true, I would dearly miss being up to my elbows in intestines. I would miss poop jokes. Would miss being a voyeur of birth, sickness, triumph, death (so that i may remain a philosopher). The novel i will write in this life will be less boring. I can wear the heels tomorrow.
In this other life, I am a very happy secretary/receptionist/personal assistant. I bathe not to make up for lost hours of sleep but so I may smell fresh and brighten the office. I wear heals. Rather than scrubs and awkward ratty student white coats I wear clothing that comes with a waistline. I have a bee hive and in this fantasy world, I wear long bright red false nails not outlawed by the CDC. They only mildly hinder my typing speed and make a pleasant clackety tip tap noise.
As a receptionist, I am hot. This is helped by the fact that I don’t have to arrive anywhere at 530 am. Nor do years of cortisol overload lead to peculiar weight distributions, terrible skin, and a diet consisting of vending machine products. I don’t worry about getting sued if my cleavage shows, and I don’t have to worry about offending people by putting my boobs in their face while I examine their ear wax and nose hairs. This is because I will not be examining their ear wax and nose hairs. I can wear short skirts and offensively ugly earings that will not get caught in my stethescope. I will not have a stethescope.
Instead of 2 years of pre med, 4 years of medical school, 4 years of residency required for training, not to mention the additional 2-6 years spent discovering genes, reconstructing the health systems of small nations, and dicking around to salvage one’s mental health, I can get pretty good at a particular office space in less than 1 year. I can already type very well you see. My handwriting is very good. And I am excellent at filing, especially when stoned.
At 5 pm, I depart and arrive at my single young woman urban apartment, and I kick off my heals and lounge on a luxurious piece of furniture which I have purchased with my single young working woman salary (which is actually a positive rather than a negative number). I sensuously pet my cat and speak in a deep throaty voice to this creature of my day’s adventures. I am allergic to cats, but in this other life I may as well eliminate other burdensome details of this one.
A girl friend calls, shall we get cocktails and pick up handsome men, and I will say no dahling I must finish my novel tonight. I make dinner or someone makes it for me, and it has real vegetables in it. I drink an after dinner brandy, since in this other life I am mentally healthy and I do not worry about a single drink dissolving my threadbare semblance of sanity and wildly sobbing for the next several days. I type. In my underwear. What the hell, I am so mentally robust I have a beer. I have 2. I smoke a cigarette, which in this other life is sexy and not so bad for you and does not prompt me like a little seal into reciting cardiovascular outcome statistics and mortality rates for small cell lung carcinoma. I fall asleep in soft sheets.
On the weekends I attend a vigorous pilates class, followed by a bloody mary. Followed by another one. I sit around in my underwear some more, typing, scratching my belly, smoking drinking napping. I have a boyfriend and he is actually something I have kept from this life. I call him poopsie, but in the other life he permits this. We have a wild and exotic love life and frequently fly to tropical islands
Of course, in this other life, I would not be a particularly good secretary, as the same things that offend me about being a medical student would persist: being bossed around. Detail orientation. Doing meaningless work. I would forget things. I would stare away into space. And it is true, I would dearly miss being up to my elbows in intestines. I would miss poop jokes. Would miss being a voyeur of birth, sickness, triumph, death (so that i may remain a philosopher). The novel i will write in this life will be less boring. I can wear the heels tomorrow.
Saturday, August 8, 2009
The Geek Girl rises
A series of event
Akward bookish childhood--> embrace nerd/geek identity
college--> find i am not alone--> become emboldened
begin pseudoactivist stance of the underrepresented presence of the Geek Girl in popular culture. Contemplate implications for gender roles in society: why are 50 per cent of math bachelor degrees given to women but less than 20 percent to physics? Why do women outnumber men in higher education, all the more in communities of color? why in Beauty and the Geek are the beauties always female and the the geeks male? and what of the beautiful geek?
Contemplate neurophysiological implications: is geek on the autism-Asperger's spectrum? why is Asperger's more prevalanet in males? What are the neurolodevelpmental underpinnings of girls speaking before boys? the role of testosterone and estrogen in cognitive function? Why do chromosomal abberations that give a deficiency in either result in passive individuals? and why are there so few studies?
The geeks inherit the earth and their base is the South Bay. They also take over Wall Street and the White House, the former to our collective regret.
Today i saw a poster for Paper Heart. I roll my eyes with snobbish contempt at instant pattern recognition--oh another 'indie' movie with that pale technicolor aesthetic, scrawly text, 'low budget' charm and whimpery cooey soundtrack. But then i noted that the heroine appears to be a very dorky looking, chubby brown Asian girl.
woot!
a debate begins "how to seduce a geek girl" spawns "4 tips for Understanding 'Girl Geeks'
http://jezebel.com/5332327/4-tips-for-understanding-girl-geeks
And i realize i don't know why so late--the geek is cool. And like all great triumphs of outsiders who become recognized, the bittersweet prize--assimilation, and thus--obliteration.
"The history of 'geek':
1515-1916 A "fool, dupe, or simpleton"
1916-1970s A circus sideshow performer who bites the heads off chickens.
1970s-1980s Derogatory term for a socially awkward or unattractive person. Usually male.
1990s A computer genius with stock options. Possibly worth billions. (In the 1980s, these were called "nerds".)
2000s and beyond Actors, models, talk show hosts, iPhone owners, fans of the top grossing movies of all time, anyone whose job description is more complicated than "shopping" "
Disclaimer: i have been told i am but a nerd and a dilletante, not a geek proper. that's cool.
Akward bookish childhood--> embrace nerd/geek identity
college--> find i am not alone--> become emboldened
begin pseudoactivist stance of the underrepresented presence of the Geek Girl in popular culture. Contemplate implications for gender roles in society: why are 50 per cent of math bachelor degrees given to women but less than 20 percent to physics? Why do women outnumber men in higher education, all the more in communities of color? why in Beauty and the Geek are the beauties always female and the the geeks male? and what of the beautiful geek?
Contemplate neurophysiological implications: is geek on the autism-Asperger's spectrum? why is Asperger's more prevalanet in males? What are the neurolodevelpmental underpinnings of girls speaking before boys? the role of testosterone and estrogen in cognitive function? Why do chromosomal abberations that give a deficiency in either result in passive individuals? and why are there so few studies?
The geeks inherit the earth and their base is the South Bay. They also take over Wall Street and the White House, the former to our collective regret.
Today i saw a poster for Paper Heart. I roll my eyes with snobbish contempt at instant pattern recognition--oh another 'indie' movie with that pale technicolor aesthetic, scrawly text, 'low budget' charm and whimpery cooey soundtrack. But then i noted that the heroine appears to be a very dorky looking, chubby brown Asian girl.
woot!
a debate begins "how to seduce a geek girl" spawns "4 tips for Understanding 'Girl Geeks'
http://jezebel.com/5332327/4-tips-for-understanding-girl-geeks
And i realize i don't know why so late--the geek is cool. And like all great triumphs of outsiders who become recognized, the bittersweet prize--assimilation, and thus--obliteration.
"The history of 'geek':
1515-1916 A "fool, dupe, or simpleton"
1916-1970s A circus sideshow performer who bites the heads off chickens.
1970s-1980s Derogatory term for a socially awkward or unattractive person. Usually male.
1990s A computer genius with stock options. Possibly worth billions. (In the 1980s, these were called "nerds".)
2000s and beyond Actors, models, talk show hosts, iPhone owners, fans of the top grossing movies of all time, anyone whose job description is more complicated than "shopping" "
Disclaimer: i have been told i am but a nerd and a dilletante, not a geek proper. that's cool.
Sunday, July 26, 2009
Malaise
I have settled into a 6 day hangover that began Tue night and has had no intoxicating percipitant. It continues unabated. How i dislike everything.
What could be the cause? I have taken almost 9 years of advanced education and training and done what the modern well-to do intellect does far too naturally--repeatedly ramming this education at the excessive dissection of my own neuroses. Is it the cold weather? am i hypothyroid? Is it a subclinical sinus infection? a dopamine failure? Perhaps i have been too inattentive to self reflection? A shortage of quiet meditation? Am i paralyzed by choice in the modern ennui of post industrial capitalism? Is my mental hygeine insufficient? And so goes the differential diagnosis of the incompletely trained young physician and meta-physician.
In my lucid moments i suspect i have merely run out of the shrill and hysterical enthusiasm that kept me afloat for the several weeks of surgery following the soul sucking devastation that is commonly known as the USMLE step 1 exam. Surgery and inpatient medicine furthermore was a great novelty. Plenty of dopamine to keep one afloat. The outpatient medicine scene i had wrongly assumed to familiar and thus easier. Although i do not arrive home in stuperous exhaustion every day, i maintain baseline level of anxiety that is mostly associated with a constant confusion as to where i am supposed to be at any given moment.
Its true, there is no 3 hours of excruciating rounds. No feigning interest in the 43rd hernia surgery you've seen and still don't get as its just a lot of flimsy layers being poked at and wasn't cooper's ligament in the boobs or something? So now i have arrived in the exotic lands of outpatient medicine and the time has come to open my soul to a new land, a new people, to patients who are not obtunded under anesthesia and have rich and complicated lives outside of the clinic, usually involving eating too much, smoking too much, etc.
Whatever the etiology of my malaise, the self-medication has remained worrisomely the same since age 14 - eating, internet, a bowl and someimes a passage or two of Bertrand Russell.
It is in these moments that the road ahead seems despairingly long. The thought of being a doctor, being organized, caring about other people, having responsibility, having any job at all, seems pointless and horrible and wouldn't i rather be...what? balancing a bowl of cereal on my gut and watching cartoons with lewd humor?
Such despair is often moderately improved with a well titrated dose of caffeine, usually with a little creme. At that point i am assured that i would indeed like to have a job, a meaningful, interesting one that affords me whatever minimal illusion that i am Part of Something Bigger, and making things on sum better rather than worse, one that i would like to be Very Good At, and always inspired to Do Even Better, and one with a steady income to boot, so as to allow funding for said bowl of cereal.
What could be the cause? I have taken almost 9 years of advanced education and training and done what the modern well-to do intellect does far too naturally--repeatedly ramming this education at the excessive dissection of my own neuroses. Is it the cold weather? am i hypothyroid? Is it a subclinical sinus infection? a dopamine failure? Perhaps i have been too inattentive to self reflection? A shortage of quiet meditation? Am i paralyzed by choice in the modern ennui of post industrial capitalism? Is my mental hygeine insufficient? And so goes the differential diagnosis of the incompletely trained young physician and meta-physician.
In my lucid moments i suspect i have merely run out of the shrill and hysterical enthusiasm that kept me afloat for the several weeks of surgery following the soul sucking devastation that is commonly known as the USMLE step 1 exam. Surgery and inpatient medicine furthermore was a great novelty. Plenty of dopamine to keep one afloat. The outpatient medicine scene i had wrongly assumed to familiar and thus easier. Although i do not arrive home in stuperous exhaustion every day, i maintain baseline level of anxiety that is mostly associated with a constant confusion as to where i am supposed to be at any given moment.
Its true, there is no 3 hours of excruciating rounds. No feigning interest in the 43rd hernia surgery you've seen and still don't get as its just a lot of flimsy layers being poked at and wasn't cooper's ligament in the boobs or something? So now i have arrived in the exotic lands of outpatient medicine and the time has come to open my soul to a new land, a new people, to patients who are not obtunded under anesthesia and have rich and complicated lives outside of the clinic, usually involving eating too much, smoking too much, etc.
Whatever the etiology of my malaise, the self-medication has remained worrisomely the same since age 14 - eating, internet, a bowl and someimes a passage or two of Bertrand Russell.
It is in these moments that the road ahead seems despairingly long. The thought of being a doctor, being organized, caring about other people, having responsibility, having any job at all, seems pointless and horrible and wouldn't i rather be...what? balancing a bowl of cereal on my gut and watching cartoons with lewd humor?
Such despair is often moderately improved with a well titrated dose of caffeine, usually with a little creme. At that point i am assured that i would indeed like to have a job, a meaningful, interesting one that affords me whatever minimal illusion that i am Part of Something Bigger, and making things on sum better rather than worse, one that i would like to be Very Good At, and always inspired to Do Even Better, and one with a steady income to boot, so as to allow funding for said bowl of cereal.
Wednesday, June 3, 2009
Week 6
The ICU continues to be frightening, but now not because it raises the questions of mortality or displays the prone bodies of the helplessly sick, but mostly because i still don't understand the vent settings.
All things can become conquerable, once they are named. Once they are named, divided, classified. Once they are named, translated and become a puzzle of cognition, technique, logical and mechanical resolution.
Grand Rounds today: surgical education. It began with a typical display of graphs. Outcomes, surveys, studies. Rigor was demanded, plus or minus p values. A new laparoscopy lab has been built, the bottom line, measured. Interns were made fun of. Papers were published. The last speaker (the one that i thought was smirky, that pimped us on Charcot's triad on day 1) ended with a discussion of his mother's death and the meaning of teaching: this [life] too shall pass. In teaching, the work caries on. We lift up others to see the future.
I got a bit teary.
Spock, 1. Kirk, 1.
All things can become conquerable, once they are named. Once they are named, divided, classified. Once they are named, translated and become a puzzle of cognition, technique, logical and mechanical resolution.
Grand Rounds today: surgical education. It began with a typical display of graphs. Outcomes, surveys, studies. Rigor was demanded, plus or minus p values. A new laparoscopy lab has been built, the bottom line, measured. Interns were made fun of. Papers were published. The last speaker (the one that i thought was smirky, that pimped us on Charcot's triad on day 1) ended with a discussion of his mother's death and the meaning of teaching: this [life] too shall pass. In teaching, the work caries on. We lift up others to see the future.
I got a bit teary.
Spock, 1. Kirk, 1.
Wednesday, May 27, 2009
Medical Student Presentation Guide
This is a rather amusing if not entirely didactic guide to patient presentations
A complete History and Physical must be obtained with the resident on the floor and written up for Dr. Miller and the teaching resident.
Presentation of morning rounds must be focused and concise. Specifically:
Give a one-line introduction with: age, sex, diagnosis(es)
Brief HPI with chief complaint, length and type of symptoms, medical interventions (if any)
ER course: Vital signs, exam in ER, interventions
Floor course: Exam if different from ER, interventions
Your plan: Medical management, studies required, etc.
Concise, effective presentations are very difficult to synthesize. To help you do this, use the intern who is assigned to the patient to figure out what information is pertinent, and give a trial run of your presentation to him or her.
You should practice your presentation and time yourself. The goal is less than two minutes! Remember to include what you feel are the PERTINENT positives and negatives. Your senior resident will ask specific focused questions if they require more information. Again, let me emphasize that we realize this is a difficult task. If you feel uncomfortable or unsure, talk to one of the seniors on your team and they can guide you through your specific areas of concern.
Examples:
Bad:
This is a three year old cute little girl who has been having a hard time breathing for awhile now. She has a doctor who manages her asthma with a bunch of different medicines but things weren't going so well, so she came to the ER with her Mother, sister, and baby doll, Mrs. Bigglesworth. Apparently, she has been in the hospital before with this and mom says she misses a lot of her preschool because of her wheezing. Mom things that she is worse in the spring but she was a little fuzzy on that point. So today after ballet class mom saw that Sissy was breathing hard and they decided to go to the ER after getting Mr. Misty at the DQ on the way, by the way Sissy got blueberry which worried the ER staff who initially thought she was cyanotic. Anyway, in the ER she was breathing fast and working hard so she was given Albuterol nebs and some prednisone which she vomited twice so she was enrolled in Steve Gordon's asthma study and given Dexamethasone. She was OK on q2 nebs so she came to the floor where she is still on q2 but looking a little better. Here on the floor, she was breathing around 68 breaths per minute and was having a hard time talking but she looked otherwise well and in no distress. Her immunizations are all current but mom is not sure if she should get the new heptavalent pneumovax. Currently, mom says that she can talk in five word phrases and she easily walks up and down stairs unassisted. Her exam on the floor is as follows. HR 118, RR 50, BP 111/68, head circumference 50 cm. Today, I think we should consider spacing her nebs to q3 hours in preparation for early morning discharge tomorrow since I know we are in a bed crunch.
Good:
This is a three year old moderate-severe asthmatic female who presented to the ER at 8 pm last night after having an increased work of breathing for one day that was refractory to Albuterol q3 at home. This is her fourth hospital admission, no PICU admissions, and no intubations. Her home regiment includes Albuterol nebs PRN, Flovent 44 mcg with spacer and mask BID and PO prednisone PRN severe exacerbation. Her triggers include cats, seasonal allergies and cold weather. Her mother and brother are also sever asthmatics.
In the ER, her respiratory rate was 68 and her O2 sat 90% on room air. Her exam revealed diffuse wheezing and pan retractions but was otherwise unremarkable. She was given IM Dexamethasone as per Dr. Gordon's protocol; Albuterol with Atrovent times three then two Albuterol nebs q2. Her respiratory distress improved significantly and she was admitted to 10 South for further management.
On the floor her respiratory rate was between 35-40, O2 sat greater than 98% with 1 liter nasal cannula O2, wt=14 kg (59th %). She continues to have diffuse wheezing but now has only a little nasal flaring. She continues on Albuterol q2 but appears to be in less distress this morning.
Today, I want to continue her nebs at q2, continue her steroid regimen and get Pulmonary to consult for asthma teaching.
A complete History and Physical must be obtained with the resident on the floor and written up for Dr. Miller and the teaching resident.
Presentation of morning rounds must be focused and concise. Specifically:
Give a one-line introduction with: age, sex, diagnosis(es)
Brief HPI with chief complaint, length and type of symptoms, medical interventions (if any)
ER course: Vital signs, exam in ER, interventions
Floor course: Exam if different from ER, interventions
Your plan: Medical management, studies required, etc.
Concise, effective presentations are very difficult to synthesize. To help you do this, use the intern who is assigned to the patient to figure out what information is pertinent, and give a trial run of your presentation to him or her.
You should practice your presentation and time yourself. The goal is less than two minutes! Remember to include what you feel are the PERTINENT positives and negatives. Your senior resident will ask specific focused questions if they require more information. Again, let me emphasize that we realize this is a difficult task. If you feel uncomfortable or unsure, talk to one of the seniors on your team and they can guide you through your specific areas of concern.
Examples:
Bad:
This is a three year old cute little girl who has been having a hard time breathing for awhile now. She has a doctor who manages her asthma with a bunch of different medicines but things weren't going so well, so she came to the ER with her Mother, sister, and baby doll, Mrs. Bigglesworth. Apparently, she has been in the hospital before with this and mom says she misses a lot of her preschool because of her wheezing. Mom things that she is worse in the spring but she was a little fuzzy on that point. So today after ballet class mom saw that Sissy was breathing hard and they decided to go to the ER after getting Mr. Misty at the DQ on the way, by the way Sissy got blueberry which worried the ER staff who initially thought she was cyanotic. Anyway, in the ER she was breathing fast and working hard so she was given Albuterol nebs and some prednisone which she vomited twice so she was enrolled in Steve Gordon's asthma study and given Dexamethasone. She was OK on q2 nebs so she came to the floor where she is still on q2 but looking a little better. Here on the floor, she was breathing around 68 breaths per minute and was having a hard time talking but she looked otherwise well and in no distress. Her immunizations are all current but mom is not sure if she should get the new heptavalent pneumovax. Currently, mom says that she can talk in five word phrases and she easily walks up and down stairs unassisted. Her exam on the floor is as follows. HR 118, RR 50, BP 111/68, head circumference 50 cm. Today, I think we should consider spacing her nebs to q3 hours in preparation for early morning discharge tomorrow since I know we are in a bed crunch.
Good:
This is a three year old moderate-severe asthmatic female who presented to the ER at 8 pm last night after having an increased work of breathing for one day that was refractory to Albuterol q3 at home. This is her fourth hospital admission, no PICU admissions, and no intubations. Her home regiment includes Albuterol nebs PRN, Flovent 44 mcg with spacer and mask BID and PO prednisone PRN severe exacerbation. Her triggers include cats, seasonal allergies and cold weather. Her mother and brother are also sever asthmatics.
In the ER, her respiratory rate was 68 and her O2 sat 90% on room air. Her exam revealed diffuse wheezing and pan retractions but was otherwise unremarkable. She was given IM Dexamethasone as per Dr. Gordon's protocol; Albuterol with Atrovent times three then two Albuterol nebs q2. Her respiratory distress improved significantly and she was admitted to 10 South for further management.
On the floor her respiratory rate was between 35-40, O2 sat greater than 98% with 1 liter nasal cannula O2, wt=14 kg (59th %). She continues to have diffuse wheezing but now has only a little nasal flaring. She continues on Albuterol q2 but appears to be in less distress this morning.
Today, I want to continue her nebs at q2, continue her steroid regimen and get Pulmonary to consult for asthma teaching.
Monday, May 4, 2009
Day 6 and 7
First call. probably good that i can't really twitter or fb in hospital. but many observations over 30 hours lost. maybe for better?
it was quiet for trauma. the ER was mostly full of non surgical stab wounds and DTs and the like. But after 8 pm two appendicitis cases. I scrubbed in on both.
I felt dorky for admitting it-these are bread and butter surgeries and laparascopies to boot--but how can i resist being insanely excited at my first OR experience? I wore gowns, double gloved, had a mask, got yelled at by the scrub nurse--everything i dreamed of! that beep beep of vital signs, the inappropriate jokes by the anesthesiologist. I even got to suture one of the ports. However i did a terrible job and we had to steristrip it (its only a 1 cm scar, i promise!)
tried not to be irritating to the residents, but they taught a lot. got to sleep 3 hours, more than most of the other medstudents this week
prepped for presentation at GI/surg conference but a surg resident did it instead, which is good bc his was much better. i got excited and spoke up, but it felt funny, a sense of breaching hierarchy. should make note of this in future--not so much to cease as to proceed with caution.
Felt pretty shitty and out of it for rest of day. Really tired, really hungry, feet hurt, back hurt, was kind of smelly, tried to speak coherently, but felt good in a deeper way, like i was doing something really tough like travelers and military and well, surgeons, do.
Biked home. took best shower in a long ass time.
it was quiet for trauma. the ER was mostly full of non surgical stab wounds and DTs and the like. But after 8 pm two appendicitis cases. I scrubbed in on both.
I felt dorky for admitting it-these are bread and butter surgeries and laparascopies to boot--but how can i resist being insanely excited at my first OR experience? I wore gowns, double gloved, had a mask, got yelled at by the scrub nurse--everything i dreamed of! that beep beep of vital signs, the inappropriate jokes by the anesthesiologist. I even got to suture one of the ports. However i did a terrible job and we had to steristrip it (its only a 1 cm scar, i promise!)
tried not to be irritating to the residents, but they taught a lot. got to sleep 3 hours, more than most of the other medstudents this week
prepped for presentation at GI/surg conference but a surg resident did it instead, which is good bc his was much better. i got excited and spoke up, but it felt funny, a sense of breaching hierarchy. should make note of this in future--not so much to cease as to proceed with caution.
Felt pretty shitty and out of it for rest of day. Really tired, really hungry, feet hurt, back hurt, was kind of smelly, tried to speak coherently, but felt good in a deeper way, like i was doing something really tough like travelers and military and well, surgeons, do.
Biked home. took best shower in a long ass time.
Saturday, May 2, 2009
Day 6
had day off. spent previous night with bf eating frozen pizza and salad.
Day 5 examined first prison patient. Remarkable for being unremarkable. Had a lump in his butt. Officer left the room during the butt exam, which caused some distress, but distress was unfounded. In general, first time examining a real patient's butt (although not a real rectal exam). Turns out to be equally weird as examining their chest, head, etc, but not weirder. Slightly weirder trying to remove someone's orange prison pants beneath their shackles, since they are handcuffed and can't remove their own pants. patient was regular, not weird or violent, and that was helpful. Two male genital exams have both been less weird than majority of female exams, but then also less invasive. I hate pelvic exams too.
afternoon spent suture workshop, practice sutures on decomposing pig feet. gross
Day 6 maybe have a cold. Went to capoeira anyway. still really out of shape, so weird to be desperately breathless--for some reason it is so beautiful and i love it, when i think about pts with COPD or intubators, and the reason i can't breathe is because i did 30 cartwheels, not because my lungs are not viable. It is frivolous and i am so grateful for the frivolity, for my health, for breath, which can leave us anytime. we all become patients one day.
Day 5 examined first prison patient. Remarkable for being unremarkable. Had a lump in his butt. Officer left the room during the butt exam, which caused some distress, but distress was unfounded. In general, first time examining a real patient's butt (although not a real rectal exam). Turns out to be equally weird as examining their chest, head, etc, but not weirder. Slightly weirder trying to remove someone's orange prison pants beneath their shackles, since they are handcuffed and can't remove their own pants. patient was regular, not weird or violent, and that was helpful. Two male genital exams have both been less weird than majority of female exams, but then also less invasive. I hate pelvic exams too.
afternoon spent suture workshop, practice sutures on decomposing pig feet. gross
Day 6 maybe have a cold. Went to capoeira anyway. still really out of shape, so weird to be desperately breathless--for some reason it is so beautiful and i love it, when i think about pts with COPD or intubators, and the reason i can't breathe is because i did 30 cartwheels, not because my lungs are not viable. It is frivolous and i am so grateful for the frivolity, for my health, for breath, which can leave us anytime. we all become patients one day.
Thursday, April 30, 2009
Day 4
First rounds this morning. Start at 6 am. The ICU is still a little bit scary. Doesn't end til 930 am. People seem disgruntled that the med students (us) are not doing what they are supposed to be doing, even though they realize we do not know what we are supposed to be doing.
We are supposed to be removing and replacing surgical dressings. We have to figure out how to do this by tomorrow at 6 am.
The rounds go until 930 am. The senior resident is dashing and charming and it is amazing how intimately he knows each of the 40 patients. The interns are post call and irate. We stay out of their way.
The clinic is over flowing. They are depending on us to keep the flow, even though at this point we cause more delay than speed. There is only one attending. Patients wait for 3 or 4 hours shivering in their gowns.
I examine a mans genitals with great authority. He has an enormous hernia and a painful swelling of his testicles. His penis is retracted. He is an ex-con, a "street warrior," his skin scarred and bruised from knife fights and heroin skin popping. He has an odd affect, a mood disorder. He follows my directions. I examine him with gloves. When i return the attending examines him without gloves and has me do the same.
I watch a pretty nurse practitioner who is about my age, expertly pull a drain from a man's stomach. She is someone like me--a normal person, a young person--but her hands and her brain are like magic. She helps me figure things out and i am grateful for her patience.
We do not end for several hours. At 2 i realize it has already been an 8 hour day.
I receive an email from a star graduating student who responds to my fretting about the future. She tells me not to fret. I believe her. She tells me to work really really hard. I believe her.
We are supposed to be removing and replacing surgical dressings. We have to figure out how to do this by tomorrow at 6 am.
The rounds go until 930 am. The senior resident is dashing and charming and it is amazing how intimately he knows each of the 40 patients. The interns are post call and irate. We stay out of their way.
The clinic is over flowing. They are depending on us to keep the flow, even though at this point we cause more delay than speed. There is only one attending. Patients wait for 3 or 4 hours shivering in their gowns.
I examine a mans genitals with great authority. He has an enormous hernia and a painful swelling of his testicles. His penis is retracted. He is an ex-con, a "street warrior," his skin scarred and bruised from knife fights and heroin skin popping. He has an odd affect, a mood disorder. He follows my directions. I examine him with gloves. When i return the attending examines him without gloves and has me do the same.
I watch a pretty nurse practitioner who is about my age, expertly pull a drain from a man's stomach. She is someone like me--a normal person, a young person--but her hands and her brain are like magic. She helps me figure things out and i am grateful for her patience.
We do not end for several hours. At 2 i realize it has already been an 8 hour day.
I receive an email from a star graduating student who responds to my fretting about the future. She tells me not to fret. I believe her. She tells me to work really really hard. I believe her.
Wednesday, April 29, 2009
Day 3
Grand rounds are boring
Found out board scores. Yay i passed. Sob, my score is lame.
Fret about future.
Thrown into clinic. Handed charts. Examine. Attending is mildly frightening. Patient gets off cell phone when i enter; "can't talk, the doctor is here." He meant me?! Attending turns out to be kind of really cool. Learn more in 2 hours then in 2 weeks. Survive.
Home. Fret about future. Decide to push on.
Found out board scores. Yay i passed. Sob, my score is lame.
Fret about future.
Thrown into clinic. Handed charts. Examine. Attending is mildly frightening. Patient gets off cell phone when i enter; "can't talk, the doctor is here." He meant me?! Attending turns out to be kind of really cool. Learn more in 2 hours then in 2 weeks. Survive.
Home. Fret about future. Decide to push on.
Tuesday, April 28, 2009
Day 2
More orientation. Does not begin till 10, even though i woke up at 6 and tomorrow i will wake up at 430.
there is still much hope in the air.
feel like the hardest part of med school is letting go of one's particularities of previous identities--namely, that of ditzy intellectual, which was a fun role to try to develope. its not as funny to have a ditzy doctor. its kind of scary. but changing such a thing brings up profound difficult questions of identity, habitus, and change. did i once develope such a role as one puts on garb, an arbitrary pair of pants found in the free bin--or did it seem a good way to deal with the fact that i have terrible short term memory? Is it essence or is it mere garb one puts on and off a deeper essence? is there no essence at all, this illusion of self?!
no time for difficult questions! have to review abdominal vasculature.
there is still much hope in the air.
feel like the hardest part of med school is letting go of one's particularities of previous identities--namely, that of ditzy intellectual, which was a fun role to try to develope. its not as funny to have a ditzy doctor. its kind of scary. but changing such a thing brings up profound difficult questions of identity, habitus, and change. did i once develope such a role as one puts on garb, an arbitrary pair of pants found in the free bin--or did it seem a good way to deal with the fact that i have terrible short term memory? Is it essence or is it mere garb one puts on and off a deeper essence? is there no essence at all, this illusion of self?!
no time for difficult questions! have to review abdominal vasculature.
Sunday, April 26, 2009
Goals
General Goals
The overall goal of this clerkship is to provide the environment needed to have you develop into a humane, sympathetic, knowledgeable and sophisticated physician. Further, our aim is to teach you to apply the background in pathophysiology you acquired in the pre-clinical years to the diagnosis and management of surgical patients.
Specific Goals
Toward this end, the faculty will expect that you will learn to:
Obtain a complete history and perform an accurate physical examination in approximately one hour.
Formulate a differential diagnosis after obtaining a history and examining a patient.
Devise a scheme of reasonable and appropriate laboratory and other diagnostic tests leading to the establishment of a diagnosis; become familiar with the availability, cost, and limitations of laboratory and other diagnostic procedures.
Formulate a plan of therapeutic management for the patient; if surgical procedures are included in the plan, be familiar with the risks and alternatives.
Be able to represent the clinical information to others in a coherent, succinct manner.
Acquire and expand on a core of surgical knowledge, including developing an awareness of sources of information, their limitations and scientific merit.
Develop a sophisticated clinical judgment, applying your knowledge of pathophysiology to clinical surgery.
Learn to interact and deal with professional and nonprofessional personnel, patients and their families encompassing social, ethical, psychological and medical aspects of such interactions.
The overall goal of this clerkship is to provide the environment needed to have you develop into a humane, sympathetic, knowledgeable and sophisticated physician. Further, our aim is to teach you to apply the background in pathophysiology you acquired in the pre-clinical years to the diagnosis and management of surgical patients.
Specific Goals
Toward this end, the faculty will expect that you will learn to:
Obtain a complete history and perform an accurate physical examination in approximately one hour.
Formulate a differential diagnosis after obtaining a history and examining a patient.
Devise a scheme of reasonable and appropriate laboratory and other diagnostic tests leading to the establishment of a diagnosis; become familiar with the availability, cost, and limitations of laboratory and other diagnostic procedures.
Formulate a plan of therapeutic management for the patient; if surgical procedures are included in the plan, be familiar with the risks and alternatives.
Be able to represent the clinical information to others in a coherent, succinct manner.
Acquire and expand on a core of surgical knowledge, including developing an awareness of sources of information, their limitations and scientific merit.
Develop a sophisticated clinical judgment, applying your knowledge of pathophysiology to clinical surgery.
Learn to interact and deal with professional and nonprofessional personnel, patients and their families encompassing social, ethical, psychological and medical aspects of such interactions.
Tuesday, April 14, 2009
Irreconcilable Aesthetic Differences
I like girls with biceps, beautiful girls with pretty smiles and rippling arms, i love girls with big hips and poochy bellies and the sound of singing, off key alone, harmonious when shouted, all of us together to the sound of simple instruments, the sort that must be struck.
I love breasts. I love the breasts of women, big giant full breasts described in metaphor, a variety of full figured summer fruit found throughout numerous geographical regions, and i love small tender breasts lean soft and pointy like flower buds, also found in a variety of ecological niches, even very harsh ones. I love the breasts of old women, when everything has dried away and hardened, the breasts of old women are still soft, even when they hang over tripping hearts, brittle ribs, when there there are worrisome calcified tumors, that sit like ominous pebbles, amid plump moss and velvet fragile skin.
What is beautiful is sweat, smelly sticky endlessly flowing salty damp cool sweat on hot skin, puddles on the floor, drenching sheets
What is beautiful is urine, smelly pussy yellow brown red and bloody, urine the secret of the soul, the window of the humors, frothy urine full of secrets, full of stories. What is beautiful is blood, dangerous sanguine, blood is still full of ghosts (they are called viruses now), and is still thick and dizzying and terrifying and life and death can be foretold in the vile.
Beauty, what is beautiful, do you love me, do you find me beautiful, this is what i find beautiful. Things like flowers, and sunrises, and an adorable list of multiple daily things that surround us but go unnoticed unless we are intoxicated. Also--things that are seemingly ugly, but on further inspection, and with the right soundtrack are also very beautiful, like the items of urban decay and industrial waste and secret worlds like prisons, hospitals, bohemia and crackheads on 16th street. Also--lovers and things that have to do with love. That is very beautiful. So too is youth, healthy food, mathematical patterns in nature, well engineered machines, you and your self esteem, small children and their mothers.
I also agree that red lipstick and young men with well defined and graceful bottoms are also very beautiful. Also, young men with glasses and computer programming skills, all though this is less commonly shared. Several types of well decorated pastries and most of the major works by Immanuel Kant--those too.
And you?
I love breasts. I love the breasts of women, big giant full breasts described in metaphor, a variety of full figured summer fruit found throughout numerous geographical regions, and i love small tender breasts lean soft and pointy like flower buds, also found in a variety of ecological niches, even very harsh ones. I love the breasts of old women, when everything has dried away and hardened, the breasts of old women are still soft, even when they hang over tripping hearts, brittle ribs, when there there are worrisome calcified tumors, that sit like ominous pebbles, amid plump moss and velvet fragile skin.
What is beautiful is sweat, smelly sticky endlessly flowing salty damp cool sweat on hot skin, puddles on the floor, drenching sheets
What is beautiful is urine, smelly pussy yellow brown red and bloody, urine the secret of the soul, the window of the humors, frothy urine full of secrets, full of stories. What is beautiful is blood, dangerous sanguine, blood is still full of ghosts (they are called viruses now), and is still thick and dizzying and terrifying and life and death can be foretold in the vile.
Beauty, what is beautiful, do you love me, do you find me beautiful, this is what i find beautiful. Things like flowers, and sunrises, and an adorable list of multiple daily things that surround us but go unnoticed unless we are intoxicated. Also--things that are seemingly ugly, but on further inspection, and with the right soundtrack are also very beautiful, like the items of urban decay and industrial waste and secret worlds like prisons, hospitals, bohemia and crackheads on 16th street. Also--lovers and things that have to do with love. That is very beautiful. So too is youth, healthy food, mathematical patterns in nature, well engineered machines, you and your self esteem, small children and their mothers.
I also agree that red lipstick and young men with well defined and graceful bottoms are also very beautiful. Also, young men with glasses and computer programming skills, all though this is less commonly shared. Several types of well decorated pastries and most of the major works by Immanuel Kant--those too.
And you?
Friday, March 13, 2009
when journeys lead to dead end bus stops and small disasters
thesis sux. filling in the references. reminded of all the cool papers i read. deeply dissatisfied to what i made from them. what was missing? what was it that really moved me? and how did i lose sight of it? hmm.
Thursday, January 22, 2009
Its really quite simple- Your Budget Guide to Cosmological Well Being
"...a neuroscientist named Jaak Panksepp who identified a series of core 'emotion system' in aminals: seeking, play, care, and lust (on the positive side) and fear, panic, and rage (on the negative).
" ' The rule is simple,' Ms. Grandin writes, 'don't stimulate rage, fear, and panic if you can help it, and do stimulate seeking and also play.' "
In the intellectual history of this strand of thought, i would organize it as follows:
Hitchhiker's Guide to the Galaxy's Comprehensive Conclusion to Total Metaphysical Inquiry
"42"
Hitchhiker's Guide to the Galaxy's Comprehensive Principle of Behavioral and Psychological Guidance
"Don't Panic"
The Grandin Moral and Social Corrolary to the HGGCPBMG
"Don't Panic Others either"
I suspect if i optimize the applications of these principles, i may save myself tens of thousand dollars on future shrink fees. Failing that, i may earn tens of thousands of dollars by developing it into a self help book.
" ' The rule is simple,' Ms. Grandin writes, 'don't stimulate rage, fear, and panic if you can help it, and do stimulate seeking and also play.' "
In the intellectual history of this strand of thought, i would organize it as follows:
Hitchhiker's Guide to the Galaxy's Comprehensive Conclusion to Total Metaphysical Inquiry
"42"
Hitchhiker's Guide to the Galaxy's Comprehensive Principle of Behavioral and Psychological Guidance
"Don't Panic"
The Grandin Moral and Social Corrolary to the HGGCPBMG
"Don't Panic Others either"
I suspect if i optimize the applications of these principles, i may save myself tens of thousand dollars on future shrink fees. Failing that, i may earn tens of thousands of dollars by developing it into a self help book.
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