There's a reason it's called the EMERGENCY ROOM...

As an aspiring emergency medicine physician, one of the things that frustrates me most is the intentional misuse or abuse of the resources of the emergency department. It is not a place to be used as a primary care facility, nor is it a dispensary of your favorite narcotic. Anyway, this being one of my pet peeves, it shouldn't be terribly difficult to see why this article really irritates me. Look, I understand that it's natural to be worried about a loved one whom you've had to bring to the ER. But threatening to call the hospital president or CEO is not merely an obnoxious tactic but one that demonstrates extreme disregard for the emergency department staff as well as the other patients. What someone is essentially saying by doing this (or any of the myriad variations on this theme) is that he is more important than anyone else in that emergency department, and that he knows better than the trained (and presumably objective) physicians, nurses, and other staff who needs to be seen urgently. If you get bitten by a tick and are worried about an acute allergic reaction (Type I hypersensitivity, for those of you who are keeping score at home), fine. But if you don't have any of the signs of anaphylaxis, it's really not necessary for you to be seen before the guy experiencing chest pain or the woman complaining of an intense sudden-onset headache. But of course, if your egotism requires you to be seen before anyone else and you manage to pull the doc away from the other patients who have been designated by triage as more emergent, you won't be the one to suffer if someone else dies, will you? It'll be the physician's fault, the hospital's fault, for not doing enough.

I've had the privilege of working with some truly outstanding emergency physicians, and I hope to be able to number myself among them someday. But when they're dealing with a waiting room jam-packed with people convinced they have swine flu, when they're dealing with full trauma bays, when they're dealing with large and uncooperative patients, abrasive family members, patients exhibiting drug-seeking behavior, and with the ever-present threat of lawsuits should the smallest thing go awry with the wrong person, can you blame them if they're a little harried, maybe slightly stressed out or on edge? And now someone wants to insist on making life MORE difficult for them and the even busier nurses and ancillary staff? I'm sorry, that just doesn't sit well with me. If you're truly in an emergency situation (the hypothetical the author poses to the physicians in the article postulates a spouse in a life-threatening state), they'll recognize it and get you where you need to go. If not, they'll still keep an eye on you; it's not like they're just going to let you die in the waiting room if suddenly your immune system DOES decide to send you into anaphylaxis. Please, give the emergency nurses and physicians the credit they deserve -- they know what they're doing. If you honestly feel that you (or the person you're with) is getting worse, let the triage nurse know - politely - and you'll likely get a prompt re-evaluation. Otherwise, wait your turn and count your blessings -- you could be one of the patients in those trauma bays. Or in ICU. Or in the morgue.

Ok, that's my rant for the day. You can see a video associated with the story below; believe it or not, the video version is actually much more tolerable than the written article. She makes it a point to indicate the kinds of problems the ER staff faces on a regular basis, and makes generally more reasonable recommendations regarding how to alert ER personnel if you really think things are going south. Once again, any questions, comments, concerns, opinions, etc. would be greatly appreciated (from all two of you who read this blog...oh well...). Hopefully we'll return to happier topics tomorrow.

Peace and God bless!

Reflections of the fragility of life

Sometimes life is a little hard to fathom. What is it that makes one little boy, apparently no different from any other, susceptible to infection by a normally benign strain of bacteria? Not long ago, he was swimming in a lake, having a grand old time; now, he's fighting to stay alive. Despite radical treatment, he may not make it. Take a look at the article describing what doctors have done so far in an attempt to quell the spread of the necrotizing pathogen. You can also take a look at the video below for a summary of the article and to hear the boy's father speaking with reporters.



In considering the case of this poor kid, I think there are a couple of things to consider. First, medically speaking, this is a bit of an enigma. Why should a normally harmless bacteria suddenly become highly virulent? Were there any early warning signs that should have suggested something was wrong? Were there any promising treatments that may have been less radical than the one the doctors chose? Have they analyzed the strain currently living at the bottom of the lake and compared it to the one rapidly consuming this young boy's body? Are others at risk? I think in any case it's probably a pretty safe bet that not too many people will be swimming in the lake in question in the near future.

The other point that this poignant story hammers home, in my opinion, is to remind us of the fragility, the ephemeral nature of this life. Life is certainly a beautiful and precious gift, but it is as fleeting as a morning mist in the face of a strong breeze. We consider ourselves to be strong, to be tough, to be hardy, and in some ways we are remarkably resilient creatures. Yet all that resiliency can be swept away in the wake of a freak occurrence like this one. But is this really such a bad thing? If we were truly as tough as we like to believe ourselves, if our lives were as permanent as a block of granite, if we did not live at the mercy of our own fragility, we might be tempted to believe that we belong here. We might be tempted to place all our hopes in this world, in this life, did we not realize that our fragility makes us as impermanent as footprints in the sand. This very element of our lives reminds us to put our trust in God rather than in the world, in eternal life rather than mortal life, for all things in this world and this life must come to an end.

Finally, I think it's also worth noting that this little boy's story could have been any one of us. There doesn't appear to have been any rhyme or reason to it. He may die, and even if he survives, he'll be disfigured for the rest of his life. It is a shocking, saddening story, and it should serve as a reminder that each day we're given is a gift. It's so easy to look to the future; I'm as guilty of it as anyone. "Well, when second year starts...when I graduate...when I'm an attending..." But what if something happens and those days never come? From where I sit now, it seems nearly inconceivable; yet, I'm sure that neither father nor son foresaw this ending to the outing at the lake. So let's thank God for His grace in giving us each day, and even as we plan for the future, let us live as best we can in the present, for the future (at least in this life) may never arrive.

So tonight, I ask you this. While the rest of the world is talking about the deaths of three celebrities, please take a moment instead to pray for this young man and his family, that God may grant them peace and healing, and that we may learn the lessons that this tragedy has to teach us.

Peace and God bless!

Primary care shortage

More articles to take a look at. This one is about the shortage of primary care docs, and what amounts to the lack of a plan to actually do anything about it (memo to President Obama: saying "we need to do something to make sure there are enough primary care physicians in the future" does not constitute a plan. Nor do vague ideas without details). It would take a special kind of person to go into primary care these days -- the hours are terrible, the acuity is low, and the pay is poor by physician standards (no minor point when most of us are looking at between $150k and $200k in debt on graduation). There are a special few out there for whom primary care, whether in pediatrics, internal medicine, or family practice, is a calling. It's something they want to do, not for the purposes of logic but for some greater reason, and I greatly respect them for that. However, unless someone comes up with an honest-to-goodness plan to make primary care more attractive for new docs, the "special few" will remain just that -- few.

Once again, thoughts and comments would be appreciated.

Peace and God bless!

Preparing for guests

My family (well, most of it, anyway) is coming tomorrow! I'll have to remember to tell Mom that I now understand why she gets stressed out when she's trying to clean the house before someone visits. Seriously, though, I can't emphasize enough how excited I am. It'll be the first time they've seen the apartment since they helped me move in last August. I have to say, though, I'm really blessed...unlike a lot of my classmates, I've had a couple of chances to see my family over the last year, and I'll have a couple more opportunities over the next year as well. I wish my brother and sister could have come too, but shockingly, I'm not the only busy one in the family. Hopefully I'll have more to say (and maybe some pictures?) over the next couple of days.

On an entirely unrelated note, I think this article is dead on the money. Again, I'd love to hear what other people's opinions are, so sound off!

Peace and God bless!

Docs and White Coats

Thought this article was interesting. I'd be very interested in hearing any comments people may have, so let me hear your opinions.

Peace and God bless!

Potpourri

So I've made some promises regarding tales of the OR as well as more about the CHP ED. I'm hoping to cover that as well as a few odds n' ends here. Let's start with the OR.

I showed up at 6:45 in the morning, finally learning why it looks like everyone in the whole hospital wears the same scrubs -- they do. Apparently there's an enormous scrub depot on one of the lower levels at Presby, and anyone working in the OR (and probably in some other areas of the hospital) is basically required to take sets of scrubs from that depot each day to keep them as clean as possible, and then to return them at the end of the day. Guess it makes sense. So from there, I got one of those ridiculous-looking cap / hair net things; apparently they're very serious about making you keep those on at all times while in the OR. They take hygeine seriously here, which makes a great deal of sense.

Anyhow, I unfortunately didn't get to see too much in the way of procedures. I saw a couple of intubations, which was pretty cool, and a neat laproscopic procedure. The highlight, though, was definitely the open-heart surgery that I got to see for a couple of minutes. Aside from seeing a living person with a wide open torso, the machinery they used was amazing. There was a very complex pump that essentially replaced the heart, pumping blood throughout the body. This was a rather large machine, with a couple of reservoirs and many tubes, and it was filled with blood. On questioning the nurses, we found out that all of that blood was from the patient; there had been no transfusions (although they had blood standing by should it have become necessary). It was truly amazing; that was definitely the first time I got a good feel for just how much blood there is in the human body.

I also found out that the stereotypes of different personnel seem to exist for a reason. The nurses I had the privilege of observing were very helpful and professional; they invested themselves in what was going on and they were very willing to answer questions and explain things. The anesthesiologist I was shadowing was tremendous -- it'd be hard to find too many clinical educators of his caliber. The surgeons...well, they were a varied group. One older surgeon has a well-deserved reputation for being a genuinely nice guy who's very good at what he does. Many were kind of aloof, although in some cases this was understandable (if you're working with someone's exposed heart, you're probably better off not letting yourself be distracted when the anesthesiologist and three med students walk into the OR). However, some were also what you might consider "stereotypical" surgeons who were abrasive to the support staff, had poor attitudes, and really just weren't team players. On the whole, though, the people that I met and got a chance to work with were phenomenal, and I hope I get a chance to get back there again. I definitely walked out of there far more knowledgable than I had been at 6:45 that morning.

So that was the OR. The CHP ED was an entirely different experience by type (no closely controlled scrub sign-out, for example) but was also absolutely amazing. Talk about a learning experience. Aside from the strictly clinical stuff (I'm thinking that should be a post unto itself), I got a first-rate education in the interpretation of C-spine x-ray and EKGs (specifically SVT vs. sinus rhythm tachycardia). It's amazing how much easier stuff is to remember when it actually applies to real people. The attending I worked with was absolutely outstanding (I seem to be very blessed in that regard) and spent time explaining these things to me in such a way that I couldn't help but understand it.

I do have one gripe about the ED, however...the layout and design is absolutely baffling. This is doubly a problem since it's so unbelivably BIG. I think you could wander for hours and still never know where exactly you were. Furthermore, the rooms are divided into blocks by acuity. Low acuity patients go in blue rooms, then yellow, then orange, and truly sick kids are in red rooms. The docs are assigned to one of these blocks. Each room has a nameplate outside the door -- you know, like "Exam room 7" or something. Each of these plates has a large colored plastic circle at the bottom. Wandering lost in the ED, looking for the red area, I figured that these circles would be a good guide. After all, it would make sense to use these to designate the room block, right? And since all the circles I was seeing were yellow, I thought that must be the yellow area. Sound logic, right? ...Except all of the circles are yellow. Apparently it was a purely aesthetic decision. Kind of like the little kitchen area that runs between two hallways, both equally accessible -- but one end has a door and the other doesnt. There are three openings in the control center for the red block, all leading to similar hallways. One has a door. Two do not. I just don't think the whole thing makes sense. I will say, however, that those are some of the nicest patient rooms (and especially trauma rooms) that I have EVER seen.

Ok, so this post is already much longer than I intended. I'll cut it off here and save the other random stuff (and the CHP clinical stuff) for later. Till then, take care.

Peace and God bless!

Yep, this is my home state...

Sad.

Corpus Christi

It's the central mystery of the Catholic faith, the source and summit of all we believe. So it seems appropriate to take a little time to reflect on the majesty of the Eucharist. I know that all too often I don't make the effort to think about what -- Who -- I'm actually receiving at Mass. It's an easy trap to fall into. After all, we live in a world where sense data is everything. I think this is especially true for those of us in scientific professions. We're taught to gather information about our surroundings and to believe only what we can see or hear or touch. Some specialties will even cautiously stretch credulity to allow what we can deduce. But in the Eucharist, we are called to look beyond that which is sensible, to see that which cannot be seen, to seek that which is hidden. So, I think it's appropriate here to include one of the magnificent hymns of the great St. Thomas Aquinas, the Adoro Te Devote:




The translation for the first verse in Latin is roughly:
Devoutly I adore you, O hidden God, truly present underneath these veils, / All my heart subdues itself before Thee since it all before these faints and fails.
For a translation of the rest, visit this site.

And another classic Thomistic meditation on the Eucharist, the Tantum Ergo (which is part of a longer chant, the Pange Lingua Gloriosi):



For the Latin and English (albeit a slightly less than literal translation), try this link.

St. Thomas makes the point that what we see in front of us is deceptive, but also reminds us that it need not be so. In our hearing, he says, we can trust so long as we are listening to the Word of God. By His promise we know that our senses fail us, and that what we perceive as simple bread and wine is in fact the most sacred Body and Blood of Christ. This is the cornerstone of our faith: that Christ, the Son, gives Himself to us under these signs. The accidents of the bread and wine remain, but the substance (sub stantia, to stand under) is that of Christ, body and blood, soul and divinity. If you want a more in depth discussion of substance and accidents, either read Aristotle (the Metaphysics, if I remember correctly) and St. Thomas or ask me. But that's not really the point here. The point is to remember the magnitude of the hidden gift, which is the hidden God -- hidden from our eyes but not from our faith and trust in Him.

One other thought before I finally go to bed (which I really should have done hours ago). Fr. Drew spoke during his homily about our lives being analogous to paintings. Our lives are made up of choices and discrete events akin to the brushstrokes made by the artist. His point was simply this: the greatest paintings, the greatest works of art, are generally understood to have some kind of underlying coherence. The brushstrokes in these masterworks are directed toward the same goal, and that unity of purpose is what makes the painting true and beautiful. When the brushstrokes are disparate and random, some may still classify the resulting work as "art," but few would call such a thing "beautiful" or "coherent." Our lives, he noted, are much the same. Our brushstrokes may be wildly incompatible; our words and our deeds may fail to match; what we do and say under one set of circumstances may vary considerably from how we respond to different conditions. There is no guiding principle, no underlying theme, and the beauty of the work is marred. For our lives to be true and beautiful, then, we must use consistent brushstrokes and constantly direct ourselves toward the same end; that is, God.

I think his analogy is brilliant and I want to take it just a bit further. When we paint this portrait of our lives, we are called to direct ourselves towards God in everything we do, everything we say, everything we are. But in so doing, in directing our lives in all things (big and little) to Christ, that self-portrait will begin to change. It won't be a self-portrait at all...and yet, it will be a perfect image of ourselves. For by completely surrendering ourselves, we will be more ourselves than ever -- more perfectly fitting images of the One in Whose image we were created.

Anyhow, those are my (hopefully semi-coherent) thoughts for the night. I still haven't said anything about the OR and I have lots more to say about the peds ED, so stay tuned for more medical stuff in the near future.

Peace and God bless!

Learning from the kids

Days like today make me realize a couple of things. First, they're a reminder of why I chose to go into medicine in the first place, and why it's important to study hard, to learn well. Being in the ED makes it all real. C. diff isn't just an abstract bug anymore; it's what's currently living in the bowels of the little kid scrunched up on the bed whimpering that's causing everything that enters one end to make a rapid exit out the other. And then micro comes rushing back, and you remember that C. diff can be treated either with IV metronidazole or oral vancomycin (since vanc isn't well absorbed orally so it goes right through the GI tract taking care of the problem as it goes). But this is real life, and more specifically, this is the pediatric ED. Oral vanc tastes FOUL, and there is no way on God's green earth that this poor little kid is going to swallow enough of it to make a difference. You see kids come in with pilocytic astrocytomas, or in status epilepticus; you get really excited about recognizing the tumor on the CT before suddenly remembering exactly what that means for the family. All of a sudden, the world of medicine is right there in front of you, not in color-coded drawings or dry textbooks, but a living, breathing person. We don't do medicine because of the theories. We do medicine because of the people we heal. We do medicine because of the lives we touch.

The other lesson that I learn -- repeatedly -- when I spend time at CHP or Presby, I'm constantly reminded of just how blessed I am. It's only by the grace of God that I'm able to be on this side of the hospital visit. Sometimes it's really easy to get bogged down in all of life's stresses. There's so much to do, and only a very limited amount of time in which to do it. It's easy to obsess over grades, over research, over crushes, over what to have for dinner tonight. Being in the ED makes you take a step back from all that and reorient yourself. Spending time in the ED gives clarity and focus to the things that really matter. Those of us capable of helping the patients who show up...well, we've been blessed. And no matter how stupid, how frustrating, how petty, how obtuse these patients (and at CHP, their parents) are, and as hard as it may be, I need to try to remember that I have been blessed and that my job now is to be a blessing to them, to be the instrument of God in touching their lives.

One other quick side commentary for future physicians: if you are in the ED and you are NOT an ED attending (say, a critical care fellow), please, for the love of God, DON'T contradict the ED attending, and DEFINITELY don't contradict her in front of other ED staff, and ESPECIALLY don't contradict her in front of the patient's family. PARTICULARLY when you're wrong. You'll seriously irritate said attending, earn the ill will of basically the entire emergency department staff, and leave the MS-II standing in the corner watching the whole thing shaking his head in disgust at the absolute lack of professionalism. What you do in the ICU is your business, but what the emergency docs do in the ED is theirs. This has been a public service announcement.

Anyhow, that's all from me for tonight. At some point I'll have to blog about my experience in the OR, but for now all I'll say is that it was both worthwhile and eye-opening. Stay tuned...

Peace and God bless!

Research

Bah. It's kind of sad that the biggest roadblock we've run into with this simulation project so far is determining which review board should be overseeing it. Is it the IRB, quality control, someone else? Does it even really need review? Do we meet the definition of "working with human subjects" or not? Gah, it's all so confusing. What I wouldn't give to be at the ropes course. Or at Still River.

Anyway, the upshot is that the rest of the research is going swimmingly. The OR director and guy in charge of surgery (I have NO idea what his official title is, but from the sounds of things, he's pretty important) were both much more enthusiastic than I thought they would be, and offered to help in any way they could. With them on board, things just got a WHOLE lot easier.

Of course, since I'm trying to design a simulation about surgery, it would be foolish to do so without experience, right? So tomorrow morning at 6:45, I'll be heading into the OR at Presby for the first time. Not gonna lie, I'm a tiny little bit excited about that. I mean, sure, the three golden rules for med students in the OR are 1) Don't touch anything! 2) ESPECIALLY don't touch anything in the sterile field! and 3) DON'T TOUCH ANYTHING!!!, but hey, it's a new experience and a kind of medicine I've never seen before. It'll be good.

Also, got my new CHP ID badge yesterday...peds ED, here I come! So among the OR, the CHP ED, and the Presby ED, hopefully I'll get to spend lots of time with patients this summer. Now THAT'S exciting!

Ok, that's all for now. I'll have more in the near future, I'm sure.

Peace and God bless!

Thoughts on Trinity Sunday

Fr. Darcy brought up some interesting points during his homily today. He spoke about how it took some 350 years for the Church to come up with a doctrine of the Holy Spirit (Council of Constantinople, 381 AD), and pointed out that of the three Persons of the Trinity, we're the least comfortable with the Holy Spirit. We have an image in our heads of the Father (inadequate as it may be), and we're more or less ok with thinking about Him as the Creator. When we use words like "omnipotent" or "omnipresent" or other words that speak of something infinite, it's generally the Father we have in mind. The Son we can most easily identify with; after all, the Son took on human flesh and "made His dwelling among us." When we speak of God as a brother, as a guide, or in human terms, it's generally Christ whose image is in our minds. But what about the Holy Spirit? We have no image of the Spirit. We picture the dove at Christ's baptism or the tongues of fire at Pentecost, but these are not comfortable images. Perhaps this derives in part from the fact that "Father" and "Son" are very human words, words for which we have concrete analogies. We have some insight into the Father because of the participation of human fathers in that archetype; the same is true for the Son. But what analogy do we have for the Holy Spirit? The Spirit is a challenge, but perhaps our inability to pigeonhole the Spirit should serve as a reminder to us, lest we be tempted to become too comfortable with our notions of Father and Son. Perhaps the enigma of the Spirit should cause us to recall that the Trinity, for all the words that have been spoken, all the ink that has been spilled, also remains a mystery to us and should be even more a cause for adoration than for study. If you're interested in reading more about the Trinity, I'd suggest St. Augustine's De Trinitate (an online text can be found here) and St. Hilary's earlier work which has been given the same title (the original title is lost to antiquity; unfortunately, if you want to read this one, you'll have to find a library. Horrors!)

In other news, basketball is fun, even in the complete absence of skills. A word of advice: if you're trying to make a defensive play, don't lead with your chin. You'll end up getting your bell rung and bleeding from a half-dozen small lip and mouth lacs. It's ok, though. Just walk it off.

Also, I'm suffering from ED withdrawal. I need to shadow. Stat. (Funny story about this: when the docs go to put orders into the computer, they have to give a time frame. Two of their choices are "now" and "stat." Being under the impression that "stat" meant "now," I of course asked about this seeming redundancy. The attending laughed and told me that "stat" means "now" and "now" means "in the next hour or so." Because that makes sense.) Hopefully this week / next weekend, seeing as I'm also supposed to be hitting up the OR on Thursday or Friday.

So I think that's about it for now. Once again I'm doing this at a ridiculous hour. I should probably fix that. Back with more updates in the near future.

Peace and God bless!

Explaining the title

You know, I had been toying with the idea of doing this for a while now, but always sort of just shrugged it off as a "why bother?" kind of thing. But then, of course, a friend comes along and starts blogging, and for some reason that finally gives me the kick in the pants that I needed to get started. Sorry, Sara, hope you don't mind!

Anyhow, I guess a little explanation is in order before I head off to bed (heaven forbid I do anything at a regular hour!). As I sat contemplating a title for this thing, my thoughts ranged far and wide. I liked the Latin title to Sara's blog (Quo Vadis?), but my attempts to come up with anything equally cool (especially given my pathetic background in Latin) were fruitless. So I started ruminating, just letting my thoughts wander, and dusted off a number of old memories. At first, they didn't seem to have much in common, but after contemplating a few, I realized that each of them represented a time that I considered important to me. They weren't necessarily big events; there were memories of sunsets on the rocks in Mattapoisett and starry evenings on the hill in Still River in addition to the vocations retreat at the House of Studies and the White Coat Ceremony here at Pitt. Each of those moments was the result of a choice, and each of those moments played a role in who I've become. And so the concept of "Defining Moments" was born (except it became "Defining Moment" because of character limits...oh well!). *edit: apparently the character limit only applies when you first name the blog. It's fixed now!* As far as the second part of the title, well, there are a couple of things to say about that. First, I wanted it to be unique and memorable, and with millions of bloggers already spilling their guts to the e-world, unique is a tad hard to come by. Second, I wanted to make a point. In terms of my identity, the two things I see as being most central to who I am are my faith and my profession (well, technically my future profession, I suppose). The order is not accidental: I'm a Catholic first and a future physician (and EM wannabe) second. I'm sure that (assuming I continue to post and this doesn't end up being a one-time deal) this will be the root of much contemplation and reflection in the years to come.

So that's the story of my blog title. At this point, I'm running out of things to say and running out of energy and attention to writing keep coherent the. Thus, I'm off for now.

Peace and God bless!