Another day a the Saint D's. It starts at 6am and it's about an hour away so....well, to make a long story short I was underslept and Dead Man Walking. At work I was bit by a ten year old. She was funny and urbane so I was fooled into thinking she was more mature than she was. I needed to wrestle an impacted tooth down out of her gum line and was going to bruticaine it out, but witty and urbane or no a scared ten year old is a scared ten year old. She chomped down hard on my finger, right on the tip. It was all my fault and as I reviewed the ultimate scenario I had created (five people packed into a small room holding down a screaming little girl) I felt like an idiot. An absolute idiot who deserved, at the very least, to have his finger mauled. I also was responsible for the worst fracture reduction ever done in the history of medicine. We eased the kid out with Ketamine and yanked and pullled on his arm. Totally incompetent. In two days he is going to take his XRays to the Orthopod clinic and that orthopod is going to have every one of his biases about crappy ER physicians spectacularly confirmed. Despite a pretty goof shift it made me feel so lousy. The truth of my situation is that even though I'm out of residency I still have a lot to learn. That was one of the appeals of Emergency Medicine, the broad domain of knowledge, but its humbling and, in times when I screw up and hurt a patient, really demoralizing. Also, I had one of those cases that I think would seem horrible from a civilian standpoint. A little Philipina woman (I think a mail order bride) came in feeling weak and sleepy. She had been vomiting and not taking her psychiatric meds. I worked her up, hydrated her, and it was time for her to leave. She flat out refused. She feigned weakness and refused to walk. She slid from her wheelchair like a limp noodle. She just wanted to be kept and cared for. The denoument involved me and the tech lifting her bodily by the armpits and dragging her to the door. Her husband had pulled the car up. We pulled her, bare feet dragging on the floor, to the door and outside. Outside, after a few seconds of her feet dragging on the asphalt her weakness dissipated and she was able to walk to the car and get in wihtout assistance. It had a certain brutal heartless air about it. How did I know this woman was feigning illness? Could I have been wrong? There's an answer, but it's a long one. In brief: that event is the whole of my job writ small; making a medical decision and acting on it. I do so in the full knowledge that at times I will be wrong. But to delay action until certainty is achieved is to be paralytic. And that's not good in an ER doc. U-561

I worked at a new place. An extra shifts that offered experience, a chance to work with residents and a little money on the side. It's good to work at new places--it stretches me. Two things stand out. First, the tech working the front desk felt sick. He had a fever and some abdominal pain. The PA he was working with chatted with him and it turned out the abdominal pain was right lower quadrant abdominal pain. Hmmmm.... So, labs were drawn and an ultrasound was done (at the desk where this guy was working!) and, Tah-dah!, appendicitis. The surgeon is called, the OR is scheduled, and....this guy keeps working. He stops working when the OR becomes available and at that point he hops into a wheelchair and lets the OR tech wheel him off. How's that for employee of the month! What a work ethic! There's no substitute that sort of personal integrity! I wrote a letter to his boss. Also, had an infuriating encounter with a radiologist. As ER docs we have a certain professional suspicion of Radiologists--their hands are so clean, their hours are so mysterious and flexible, and they have this superbly convenient screen (me) between their decisions and their consequences. So, to continue, I had a preganant woman in a motor vehicle collision. Minor, but she had real back pain and real tenderness. Also pelvic tenderness. I wrestled with the issue of radiation to the fetus and finally committed myself--a chest XRay (shielded), a knee film (shielded) and a head on Lumbar Spine film and Pelvic AP. Shooting radiation right into that baby. It felt creepy, but I had the facts on my side and I knew it. The radiology techs refused to do it. I felt the anger rising inside me (somehow I interpreted their refusal as a slur against my decency and medical judgement). I readied myself to beat on them with the power of my MD and dress them down. But I realized that was inappropriate and shitty. I eased myself down and after agreeing with them that it felt creepy (it did) I said we should go to the radiologist and have her explain the risks and benefits. I was confident I knew the risks and benefits, but thought this was a good way to deal with the potentially combustible situation. So we went to Dr. Sutter and....she didn't know shit. It was as if the idea of a pregnant woman ever needing XRays had never been addressed in the history of medicine. She knew nothing. And she was proud of it. "That's way too much radiation" she said of my plan. What was acceptable, I asked. No idea. Well, how much radiation in each of these studies? No idea. "That's something a phycisist would know." she said. Well, I am a physicist, I have my BA in it and, let me me assure you, physicists don't know shit. They sure as hell don't know ionizing radiation tolerances for 32 week fetuses. You know who does? Competent radiologists. Unfortunately we didn't have one. So, I knew I was right on this one, I got some supporting documentation, and on my authority it was done. Arrrggghhhh! Infuriating. Okay...in other news, told MA about the Biscuit situation. Her advice is no, no, don't propose in the plane. Wait until you land...she'll want to hear what you say. Hmmmm, I'm not sure I have anything clever to say, but there it is. I'm not so foolish to ignore the advice of a good female friend on a matter of such a delicate nature. I'm in count down mode--ask her Mom Thursday and fly out that night (less time for her chatty mom to spill the beans). Or maybe Wednesday....we'll see. U-561

The pressure on the modern man is outrageous when it comes to proposals. Buying the ring is just the entre into a world of irrational feminine expectations. The proposal, as Radiant told me as I was allowing my credit card to cool off before plucking it off the Robbins Bros counter and slipping it back in my wallet, must be "creative." "Creative?" Come on, give me a break. I mean, I agree in principle, but I just chafe under burden of new expectations. If someone handing you a mulit-thousand dollar ring doesn't make the event more or less memorable in and of itself then, well, I don't know what to tell you. Having so said, I've got a great idea! Skydiving! She's never gone, I've never gone and, assuming things go well, years from now we'll both think fondly of our engagement whenever we're plummeting out of the sky. The chief drawback (aside from death) is the spectre of a fumble during the handoff and the ring falling into the endless expanse below us. As God is my witness if that thing goes out the door I'm going after it and gravity be damned! Okay, its going to be skydiving. Get to SF on Thursday, go skydiving Friday and propose before the jump. A lot of the appeal for me is the symbolism. I'll make some calls and see what can be arranged. We'll see how it goes. U-561

Great, great shifts at work. Now in the fog of being underslept the details fade, but I have a clear recall of....well, mainly of a 600 pound woman. But there's a closet industry of doctors making fun of their fat patients and I feel no obligation to add my two cents. The good part of this patient's management were that the ED staff worked well as a team and that I somehow thought of ordering an ammonia level (really just checking off the boxes on the AMS algorythm) and was rewarded with a sky high reading of 170+. I knew it was pure luck, but I think I played it off in such a way that it appeared to be skill or, possibly, medical acumen. Also, one of my colleagues saw a Neisseria meningitis in a kid. Tapped him (pure pus) and loaded him on triple antibiotics. Saved his life. Undeniably. That is why my profession exists--I tap a hundred kids a month for the one in a thousand chance of finding the baby with bacterial meningitis. Ooooh--also saw a nice almost text book presentation of intussusception. I'll spare the line-by-line summary, but it was two good shifts. I always work like a dog at work. Always frantic and feeling like it takes all of my energy and attention to keep the wheels on the bus, and always leaving work an hour late pr so. But I always like it. I really like my job. Fuck it, I love my job. On Sunday I picked up the Biscuit and her mother and went to church with them. It's part of my campaign to win the old lady over. I know going to church in an effort to thaw out a future mother-in-law does not qualify as "religious devotion" in the strictest sense of the word, but a) I'm damn sure I'm not the only one whose ever done it and b) Jesus, I have no doubt, is down with this. Her church was in fine freaking form. It's "Charismatic" which is apparently a euphamism for "everything about Protestants that sets Catholics' teeth on edge." You wouldn't believe this stuff. Several times during each service I find my self looking heavenward and thinking "Look, I just want you to know, I'm just here for the old lady." And at those moments a beam of light rends the clouds and..... So, today they had a guest pastor and he was a Super Charismatic who manged to work disparaging Jews and Muslims into the first five minutes of his performance before moving on to some faith healing and self-aggrandizement. The Biscuit (and her Mom) walked out early on this buffoon and the three of us eased our disgust with the tender ministrations of the Chili's burger menu. Today....I have very humble goals that involve new Ikea furniture, a screwdriver, and probably some laundry down the line. U-561

I decided today to check out what other bloggers had put up on the web. With this"blogger.com" site it is just ridiculously easy to randomly pop in and out of people's sites. It's pretty damn interesting out there. The highlight by far was a blog of this American couple in Holland who just had a baby! It's kind of hard to imagine thematic matieral more compelling than the entry into the world of a new human life. The rest of the blog offerings run the gamut from interesting notes on life to....well, to a lot of stuff that is pretty--what the word?--lame. I noticed two trends of note: people whose blogs say something like "Go away and don't read" and blogs that are purely commercial/informational. The latter are simply uninteresting, but the former are (to my refined tastes) nauseating. Implicit in the act of blogging is the possibility/hope/expectation/conceit that someone will read one's writings. To pretend otherwise is disingenuous. It made me think about the purpose of my own blog. Despite the title, it certainly is not nautical in nature. Nor, barring some startling and unexpected life changes, do I anticipate it ever will be. It will be pretty muuch the unfocused musings of a 30 year old MD in California. As purposes go that's pretty modest, but....I think that's about right. I expect it will be heavy on medical topics because with the exception of my girlfriend (and now that the Tour is over and Lance has retired) that is the facet of my life that has the greatest hold on my psyche. Also, I think the world of medicine, particularly Emergency Medicine (note the capitalization affirms its rightful place in the House of Medicine) is pretty damn interesting. Having so said, let me enthrall you with a tale of my 2.125 patient per hour day! Eight hour shift (took me 8:40 to get out because of a infurniating radiology screw up! This would have been my first chance to leave work on time! Damn Radiology!). Okay, this obsession (for such I mjust admit it is) with my patient per hour (pph) stats is, I realize, of no interest to anyone. But for me it is of paramount importance! I work in a partnership where we basically eat what we kill. (Yes, a poor metaphor for doctors...fogive me). Think of us as a primitive tribe of Paleolithic hunters on the African plains--stalking the elusive Medicare reimbursement. Some hunters are strong and some are weak--and the weak are kept alive by the efforts of the strong. As the new guy I am aware of my weak status and feel tremendous pressure to get as strong as possible as quickly as possible. It's not right for the better docs to take less money home to their families because I'm an incompetent screw up. So, a 2.25 pph day is satisfying--after two months it's only my second shift on the right side of the 1.7 pph line that seems to separate the strong from the weak. The astute among you, or those nursing a cold, will have realized that in my brief discussion of Strong and Weak MD's, no mention is made of actual provision of patient care. More on this later, but for now...Welcome to American Medicine! U-561, M.D.

So that lady died. At times like this fellow doctors say supportive things like "No one will blame you for not being able to cure mortality". Which is one way of looking at it. Another way of looking at it is that, really, at least slowing down mortality is part of the job description. Hmmmmm... I was on a day shift and somehow I convinced myself it was a nine hour shift when, in fact, it was only eight hours. So I worked an extra unpaid hour and, because I had some loose ends hanging and dictations to do, I stayed another hour on top of that. So a ten hour shift, but only eight hours on the clock. The nice part of this is I saw 25 pts and that makes my patients per hour (kind of an ER batting average statistic) 3.125. A little over the top. Even if all 10 hours are accounted for it puts me at a yeoman-like 2.5 pph. And that will compensate for my early days on the job when I saw......much, much, fewer. U-561

Last night at work I was in the zone. It was like the patients were moving in slow motion. Weren't too busy so everyone got the special sauce: updates, pillows, little conversations with family members. All the non-billables that patients love and Medicare doesn't pay for. Also had some sickies. One woman was brought in after "arresting" in her nursing home and being brought back with CPR. At first I thought the story was bogus, because she looked pretty good for having been dead twenty minutes ago, but as she started looking shitier and after I called up the Casa Decrepitude to get the facts of the case I decided maybe the story wasn't so preposterous. Tubed her and watched her anxiously until we got the intensivist on the phone. The beauty of tubing someone is that you've got an automatic dispo--there's no argument about where a lady hooked to a two hundred pound ventilator is going to spend the night. Tubed another lady. A lady I had first met 8 days ago when I decided to treat her pneumonia with outpatient PO's. Now that decision seems unwise. I had arranged for her to get next day follow up with her PMD, but that......fell through. So now, a week later, she's being managed with 23 cm of polypropylene tubing and Zosyn. Shit. Went home feeling tired but decent. The Biscuit had cancelled her plans so she could come over to the new aprtment and cook me enchiladas and watch a movie. What a girl! She's a phenom and a damn good cook. We watched "Over There", put down a bottle of Trader Joe's $7 Sauvigbon Blanc and I was in bed and asleep by 10. What a good night! U-561

Lucky Day

I had a good night shift. It was slow and I decide to go down to the Physician lounge to grab a....forgive me...white chocolate mocha. Before leaving I said to the MS4 "You have the floor" which is what my old surgery resident told me after helping to put out a fire and leaving me to finish off a night of call in the ICU. Obviously, dropping it on a MS4 who wants to go into Peds is something different, but....so be it. In the hallway I heard a commotion and then around the corner they wheeled this young black guy with blood streaming from his eyes. It was horrifying, and I felt totally inadequate to the task that I knew lay before me, but the first thing that popped into my mind was some obscure allusion to Oedipus. I just knew that the guy was going to need care and that I would have to provide it as best I could. From his friend I got the following story: Minding their own business, driving through P-town at 2am, and shot in the head. We put the guy on a gurney and, yes, he has a hole big enough for me to stick my thumb in about three millimeters lateral to his right eye. Holy shit! I'm struck by the fact that the guy looks pretty good for a GSw to the head, but I figure it's early and things are only going to get worse before they get better. I decide to step in with some early aggresive management and then reassess the situation. I page Neurosurg, tube the guy, and then take a closer look at the guy. This requires some pretty aggresive blood clot debridement. The bleeding is not coming from the eyes, but from a few lacs around the orbits. And there is an exit wound over his right ear---well I'll be damned! This guy may have lucked out! And a CT shows he has--bullet ran right along his temple, never penetrating the cranium. In fact, the worst thing that happened to this guy tonight was some panicky ER doc put him down and intubated him. Well, the ICU doc can rememdy that in the morning. I check his ocular pressure to make sure I don't have to do a (shudder!) lateral canthotomy and eventually send him upstairs. Miraculous! When his brother shows up he tells me this guy has been shot twice before, and when the police show up they arrest the buddy who drove him in and explain that some recent paroles of gang members has led to a surge of violence in P-Town. Apparently black gang bangers trying to reclaim turf from the Mexicans who have moved in. Great. Fucking great. Glad I could help out. It just goes to show that what we say is really true: Nobody gets shot who doesn't deserve it. U-561

Lousy days at work. I went in to work sick on Saturday. Over the course of the ten hour shift I went from just a small niggling sense that my body wasn't quite right, to sneezing and chills, to a throat that felt like I had swallowed broken glass. I was miserable and could barely hold on. Didn't do any of my paperwork and went home to crash. The Biscuit was there. I took Tylenol, Motrin, Phenergan with codeine, and slept for twelve hours. Awoke feeling sick and congested and had to go back in. Then, to top it off, my boss came to talk to me about a pediatric hyperglycemia case I mismanaged. No harm, but he's right--I didn't do a very good job. Shit. U-561

Hi. I've kept a journal for a while (10 years), but lately I've just lost track of it. I always thought that the life I've been living--I was a resident in Emergency Medicine--would be interesting to someone and that I should write a book. That never came to be and......yeah, it's time to face facts, it's not going to. Not anytime soon. So--blogging for me. In preparation I have tossed the TV and bought a bottle of Plymouth Gin. We'll see how it goes...... Now seems like a good time to dive in. I just turned 30. I just quit 11 long years of higher education (4 of college, 4 of med school, and three of residency which, while technically "work", sure as hell gets paid like "education". I've stumbled my way into a good job and still find my head swimming from making $15K for my first month's work. Crazy. I've bought an engagement ring and, God willing, these pages will soon be filled with syrupy unreadable stories of a romantic engagement in San Francisco. Or, possibly, a rather turgid "Farwell cruale world.." note that might make for good reading also. New apartment, new city, and if things work out maybe a new dog. This confluence of beginings seems auspicious. I mentioned that I hoped to become engaged soon. I've done the first part--well, if you count meeting the right girl the first part then I've done the second part and bought a ring. The Biscuit and I hadn't talked about it and I had no idea what sort of ring she might like. Diamond, yes, but beyond that I was at a loss. Fortunately, she has a great friend, Radiant. I picked her up when the Biscuit when out of town for the weekend and we went to Robbins Brothers. I know, I know...pretty corporate for an engagement ring, but we were just looking for ring styles since I was going to buy the diamond in the LA Jewelry qaurter. And you got to give the devil his due--the Robbins Brothers do a damn fine job. Cold sodas, obsequious sales girls, charming"closers", the works. Radiant knew exactly what the Biscuit wanted...it's almost like they had talked about it. Princess cut, platinum, three-stone. Carat, Radiant told me, was "up to me". Thanks. Nice to be part of the process. I'm type A--a lot of us are in medicine. And I had researched the hell out of this. The whole cut, clarity, carat, color mantra. Also the artificial price inflation, the Rhode's slave-colonization that still lies at the heart of the industry, etc. Buying into the manipulative marketing and the exploitation and the materialism of it all makes my skin crawl! Still--I couldn't justify rebelling against the corrupt, insidious, blood-fed diamond industry by buying my girlfriend a shitty ring so I decided to bite the bullet and just put the money down. And let me assure you, particularly you amorous guys, it's a shitload of money! I dropped $3000 at Chez Robbbins and that was for the F-ing SETTING! A resident's monthly salary buys you a SETTING! I won't go into the gory details of wrangling for a center stone but let me put it this way--I love the ring. I'll be proud to see it on her finger and proud to have her show it to her friends and colleagues. I periodically take the ring out of it's box (hidden in a manilla envelope in my sock drawer) and gaze appreciatively at it. And when I do I think, "Shit, I could have bought a Camaro." Okay, I'm enjoying the blogging, and I expect I'll be back soon. Even so, wish me luck--I have to talk to her mom (Shiver) and plan to propose in early September. U-561