I recently returned to the west coast from Minnesota, visiting family and friends, which was wonderful as usual. In my original attempt to get to Minnesota, I was held up in Portland because the sky decided to release unheard of amounts of snow in Portland. About 14 inches in one day. This never happens in Portland, we get that kind of snow, and then some, in the mountains, but not "in the valley" as they say.
Portland was paralyzed.
Major highways were closed.
People were snowed into their homes.
Chains on tires were a common site (which is still weird to me, a native Minnesotan.)
And the airport shut down. All flights in and out were canceled on the 21st, the day I was to fly to Minneapolis. So, I rescheduled for Christmas day, the earliest flight I could get, and made the most of a snowy Portland. It ended up being just peachy.
In any case, I made it out, and back on the 3rd of January after a great time at home. Upon my return, all of the snow had melted from the "Arctic Freeze" as the news had so annoyingly called it. I had a day to unpack, repack, and check a map to find out where exactly on the coast I was to be heading the following day.
I had a house rented in a little town called Nehalem, smooshed between Wheeler and Manzanita, on the Oregon Coast. So, I began packing, and mapping, and towards the time of my departure, I looked out the window and noticed it had begun to snow, hard.
"Crap." I thought.
I had to leave that Sunday night, because I started my next rotation the following morning at 6 AM. And it wouldn't be too bad, I am a Minnesota native, I'm used to driving in snow, and I have a large, heavy, surprisingly reliable car in the snow; Betty, a 1989 Cadillac DeVille. She's cool.
But, I knew that if in the Valley it was already puking snow, it was going to get pretty bad driving through the coastal range to get to the Pacific Ocean, my new home for 3 months.
I tried not to think about it. But as I hit the road, Highway 26 was already white, and bore little resemblance to a road just outside of town. At least this 'road' is straight, and free from fallen rocks, and dizzying cliffs only feet away from the tires of my car. Though, that was precisely where I was headed.
My knuckles were already white with anticipation; white with a kung-fu grip on Betty's wheel.
"Sorry Betty, I don't mean to choke you, but this road suuuuuuuuuuuucks, and it's going to get worse."
I press on. At each exit, scores of cars decide better of their coastal pursuit, and peel off to separate gas stations, and rest stops to plan their next move, a smarter move than continuing on... as it would only get much worse.
I wasn't that smart, or maybe I was brave... well, not brave, but too proud.
"I'm from Minnesota, I'm used to driving in this kind of weather."
"Well, Mr. Pride, that's sort of true" my good sense thought, "but in Minnesota they salt, sand and plow the streets, AND they don't have mountains like the ones to which you must cut through tonight."
"Pish-Posh! I'm doin' it!" says my pride.
I press on through the black of the night, which is starkly contrasted by the thick white waves of snow that pelt my windshield, and the growing blanket that seems to cover everything around me. I begin to approach the mountains; the road winds, narrows and climbs as it presses on through the coastal range.
Even in perfect weather conditions, much of "The Sunset Highway" needs to be driven carefully, and slowly, as its course winds through the path of least resistance which was cut through the land years ago. And even in these perfect weather conditions, at times, it feels like you are not even on a road at all. It feels like you are floating through the forest, a forest of ancient, towering pines who stand triumphantly, but reassuringly. They make you want to stop your car. They make you want to get out, and just be there among them.
Tonight, it's even more beautiful, the bows of these giant pines are bending under the weight of about a foot of fresh snow. They all seem to point point directly at me as I pass, very slowly by. This white blanket seems to blur the lines between the road and the forest even more than usual. I can see no road; only white. I feel like I'm on a path through the woods, to somewhere with promise, somewhere where there is a good friend, a warm embrace, a crackling fire.... something wonderful. In this moment, it's perfect... I can't seem to recall anything more beautiful.
For this beauty, there is however, a beast.
I am more white-knuckled than ever. I have much faith in Betty, but she's never been tested like this. For that matter, neither have I. The softness of the snow, and fresh powder which characterized the pass and the majority of the mountains was easy enough to navigate, but as I begin my decent down the west side of the range, and nearer the Ocean... the temperature begins to rise. The large puffs of snow that seemed to resemble floating cotton balls begin to transform. The relative peace, and tranquility- the silence of my journey... in actuality, and in my mind- begin to change. The tires that had been soft, and silenced by the fresh, airy snow, now became noticeable. The windshield wipers spring into action, to clear the now freezing, sleet like rainy-snowy mix from my view. The road feels as if it is coated with KY jelly. Betty morphed from a staunch, Minnesotan... a TRUE viking, conquering the terrain presented to her, into a drunk 19 year old, high-heeled wearing co-ed, walking down a slippery frozen campus sidewalk just after an ice storm.
Betty was skating down the pass, and she wasn't alone. Other cars, and their occupants, were turned into fearful 2000 pound curling stones without a proper broom to guide their path.
We made it through this hybrid storm, Betty and I.... the worst was over, after some downhill fish-tailing, and fear of pulling some unintended 360's. The road began appearing through the white that covered it. And this is when the wind began.
Once the snow had disappeared, and completely transformed into rain, the coast was in site. The bent sideways trees and bushes along the cliffs next to me were testament to the fact that this day's strong winds were not anything unusual. These trees had grown up with such staggering wind, that the position in which they were currently resting, was not due to a current gust, but were a result of years of constant battering from the wind and rain. They don't even seem to move anymore with the powerful blast of air, but Betty does.
WHOOOOSH! Betty is pushed quickly to the left, and she isn't a small drink of water.
WHOOOOSH again, and a slap of water, like a wave, hits me on the right, as if the ocean had a fire hose aimed at me while I flickered through the trees as I drove down the coastline.
The water wasn't a constant pour, it came in waves, just as if I was actually driving along side the breakers on the beach. And I kept waiting for Betty to take flight, albeit a quick one... one that ended in betty on her back, and me fairly unhappy.
It is beautiful. It is scary. I am alive. I am lucky to be here, to be right where I am.
This is perfect.
I made it through the blizzard, through the mountains, and finally, through the tsunami, to my new beach-side home. I finally ease my grip on Betty's wheel. The feeling returns to my hands... and I embark on my next journey; day one of Family Practice.
I'm the new guy again. I guess, after all, I am Newguy.
cn
Sunday, January 11, 2009
Wednesday, December 17, 2008
who pooped the hall? a tribute to it's always sunny
Let me preface this by saying that it's going to be much more entertaining to those of you who watch It's Always Sunny In Philadelphia, which puts the entertainment value at only slightly more than will be outweighed by the time and energy it takes to read this. but... you're here already, right? so read on....
To those of you familiar with the mystery of 'who pooped the bed' from season 4, i believe, of It's Always Sunny In Philadelphia, I had a similar mystery the other day. No, I did not poop the bed, nor did someone sleeping next to me poop the bed, mainly because nobody sleeps there next to me, but more than that, the mystery poop appeared at work. And no, again, it did not appear in a bed... there aren't beds at the clinic, and no, it did not appear in the toilet. That's not a mystery.
It was toward the end of the day, when I was in the office, down the end of a long hall which is lined by exam rooms. The hall leads to the front nurses station, and office, which are separated by a door, and front desk that meet the waiting room, full of toys, pretty landscapes painted on the wall, and a large tropical fish tank. It is easy to see that this is a Children's Clinic. I sometimes wish I could play in the waiting room. They even have a Plasma HDTV. Not too shabby.
Despite my wishes of waiting room playtime, I was stuck at the other end of the hallway, in the Physician's/Physician Assistant's office where we do our dictating, and whatever it is we do when we have a free moment. There are no toys in this room.
From my seat, I can peer out the door, and see most of the way down the hall, except for one room, which is hidden by a twist in the hallway. Other than that, I can see if I have a patient waiting for me...
It was in a peek such as this, that the other day I noticed a patient was waiting to be seen by me. So, I got up off my lazy butt, grabbed my stethoscope and headed meaningfully toward the room in which my patient was waiting. As I got only a few steps down the hallway, painted with leaves, hills, blue sky and birds.... I heard a "step carefully!" from one of the docs, and then noticed in my pace toward the exam room, a new piece of flare decorating the hallway; a turd.
I danced around it, no problem.
"Don't wanna get that on my shoe" I thought.
In retrospect, I'm surprised I didn't think it was weird, or gross, or even that funny. It got funnier later, when I had a second to think about it. But upon first pass, I just thought... "whoa, don't step on that log in the hallway."
And it was a log, not a little pebble of a turd, not a smear from a diarrhea related spurt from a little kid who just couldn't hold it. This was a solid, whole, formed adult sized poop.
It was only on the way back from seeing my patient, when I passed by the scene of the crime that I had a moment to think about it, to think of scenarios as to how turd ended up in the middle of the hallway. And, more than that, how no one seemed to know how it got there. It just appeared out of nowhere.
My mind thinks in movies... small movies, you could call them short, independent films, the kind that don't get released throughout the entire US, but just the trendy cities. They might win some accolades, some nerd movie awards, but not this one. All I could picture was some poor little kid, but not too little, judging by the size of the excrement, in the doctor's office for one reason or another. He's hating life, simply because he's here, probably for a runny nose - because that's what they're usually in for.
I sometimes picture them in the waiting room, these 3 year old kids, playing in the waiting room, like a prison yard.... "What are ya in for?" one would ask the other.... and after the obligatory "I'm innocent, I aint sick... my mom screwed me over, got me thrown in here!" one would admit, albeit reluctantly, after sneezing and creating two extraordinarily large green snot bubbles at the end of his nose.
"OK, I might have a runny nose."
And after a good ribbing by the innocent one, he'd get far too into his verbal assault and laughing that he'd suddenly vomit directly onto the pile of blocks with which they'd both been playing. He'd just look at the other.... "You didn't see NOTHIN'! Got it?!"
(Movies... you see. It's entertaining.)
Where was I... OH yea! So I imagine this poor kid, probably around 5 or so, much too old for a poop accident like this. He's sitting in jail, for something he didn't do, when it hits him.... "gurgle....grumble, grumble."
"Oh, sh..."
and in comes the doctor, "what's the deal with this runny nose?"
"gurgle, gurgle gurgle..." say his insides...
and he's much too little, and shy to say, "Please excuse me, I need to use the restroom." So he rides it out, just hopes that the schmuck hurries up with the listening to the lungs and wh.... wait, wait, why are you listening to my belly, no, no... it's fine, it's fine... for the love of GOD don't push on it!
"gurgle, grumble, grumble!" It's too much!
and just like that, it's over. the mystery poop has begun it's journey by escaping from the large colon, through the gates of sphincter, and into the dark, warm recesses of underwear-ville.
Now Brandon is in real trouble. He can't tell his mom that he pooped in his pants. he'll be in HUGE trouble... these are new underwear! He can't tell the doctor, he'll probably give him a shot! And he's not sure how, but the nurses are in on it too.
His only option is to escape, quietly and quickly, just the way he came in. Right down the long hallway, and out the front door. He'll have to dispose of the poop somewhere between here and home, cuz mom will surely smell it in the car on the way home.
The quandary of where to unload the poo is fleeting, for like the quandary itself, the poo doesn't stick around too long. It senses it's chance to go down in history as the mystery poop when Brandon slinks off the exam table.
Underwear be damned! It's all about pant leg now!
A short couple of steps later, behind mom, the turd finds freedom as it slips past the shoe and his the floor rolling, in all it's smelly, mysterious glory.
at least that's how i like to think about it. And i like to think about all the panic Brandon went through, and then the eventual triumph he must have felt in his perceived success.
it's a great story of, um... poop... and as Frank Reynolds once said "Poop is funny!"
I hope you enjoyed it.
Merry Christmas
To those of you familiar with the mystery of 'who pooped the bed' from season 4, i believe, of It's Always Sunny In Philadelphia, I had a similar mystery the other day. No, I did not poop the bed, nor did someone sleeping next to me poop the bed, mainly because nobody sleeps there next to me, but more than that, the mystery poop appeared at work. And no, again, it did not appear in a bed... there aren't beds at the clinic, and no, it did not appear in the toilet. That's not a mystery.
It was toward the end of the day, when I was in the office, down the end of a long hall which is lined by exam rooms. The hall leads to the front nurses station, and office, which are separated by a door, and front desk that meet the waiting room, full of toys, pretty landscapes painted on the wall, and a large tropical fish tank. It is easy to see that this is a Children's Clinic. I sometimes wish I could play in the waiting room. They even have a Plasma HDTV. Not too shabby.
Despite my wishes of waiting room playtime, I was stuck at the other end of the hallway, in the Physician's/Physician Assistant's office where we do our dictating, and whatever it is we do when we have a free moment. There are no toys in this room.
From my seat, I can peer out the door, and see most of the way down the hall, except for one room, which is hidden by a twist in the hallway. Other than that, I can see if I have a patient waiting for me...
It was in a peek such as this, that the other day I noticed a patient was waiting to be seen by me. So, I got up off my lazy butt, grabbed my stethoscope and headed meaningfully toward the room in which my patient was waiting. As I got only a few steps down the hallway, painted with leaves, hills, blue sky and birds.... I heard a "step carefully!" from one of the docs, and then noticed in my pace toward the exam room, a new piece of flare decorating the hallway; a turd.
I danced around it, no problem.
"Don't wanna get that on my shoe" I thought.
In retrospect, I'm surprised I didn't think it was weird, or gross, or even that funny. It got funnier later, when I had a second to think about it. But upon first pass, I just thought... "whoa, don't step on that log in the hallway."
And it was a log, not a little pebble of a turd, not a smear from a diarrhea related spurt from a little kid who just couldn't hold it. This was a solid, whole, formed adult sized poop.
It was only on the way back from seeing my patient, when I passed by the scene of the crime that I had a moment to think about it, to think of scenarios as to how turd ended up in the middle of the hallway. And, more than that, how no one seemed to know how it got there. It just appeared out of nowhere.
My mind thinks in movies... small movies, you could call them short, independent films, the kind that don't get released throughout the entire US, but just the trendy cities. They might win some accolades, some nerd movie awards, but not this one. All I could picture was some poor little kid, but not too little, judging by the size of the excrement, in the doctor's office for one reason or another. He's hating life, simply because he's here, probably for a runny nose - because that's what they're usually in for.
I sometimes picture them in the waiting room, these 3 year old kids, playing in the waiting room, like a prison yard.... "What are ya in for?" one would ask the other.... and after the obligatory "I'm innocent, I aint sick... my mom screwed me over, got me thrown in here!" one would admit, albeit reluctantly, after sneezing and creating two extraordinarily large green snot bubbles at the end of his nose.
"OK, I might have a runny nose."
And after a good ribbing by the innocent one, he'd get far too into his verbal assault and laughing that he'd suddenly vomit directly onto the pile of blocks with which they'd both been playing. He'd just look at the other.... "You didn't see NOTHIN'! Got it?!"
(Movies... you see. It's entertaining.)
Where was I... OH yea! So I imagine this poor kid, probably around 5 or so, much too old for a poop accident like this. He's sitting in jail, for something he didn't do, when it hits him.... "gurgle....grumble, grumble."
"Oh, sh..."
and in comes the doctor, "what's the deal with this runny nose?"
"gurgle, gurgle gurgle..." say his insides...
and he's much too little, and shy to say, "Please excuse me, I need to use the restroom." So he rides it out, just hopes that the schmuck hurries up with the listening to the lungs and wh.... wait, wait, why are you listening to my belly, no, no... it's fine, it's fine... for the love of GOD don't push on it!
"gurgle, grumble, grumble!" It's too much!
and just like that, it's over. the mystery poop has begun it's journey by escaping from the large colon, through the gates of sphincter, and into the dark, warm recesses of underwear-ville.
Now Brandon is in real trouble. He can't tell his mom that he pooped in his pants. he'll be in HUGE trouble... these are new underwear! He can't tell the doctor, he'll probably give him a shot! And he's not sure how, but the nurses are in on it too.
His only option is to escape, quietly and quickly, just the way he came in. Right down the long hallway, and out the front door. He'll have to dispose of the poop somewhere between here and home, cuz mom will surely smell it in the car on the way home.
The quandary of where to unload the poo is fleeting, for like the quandary itself, the poo doesn't stick around too long. It senses it's chance to go down in history as the mystery poop when Brandon slinks off the exam table.
Underwear be damned! It's all about pant leg now!
A short couple of steps later, behind mom, the turd finds freedom as it slips past the shoe and his the floor rolling, in all it's smelly, mysterious glory.
at least that's how i like to think about it. And i like to think about all the panic Brandon went through, and then the eventual triumph he must have felt in his perceived success.
it's a great story of, um... poop... and as Frank Reynolds once said "Poop is funny!"
I hope you enjoyed it.
Merry Christmas
Thursday, December 11, 2008
a painful realization
i accidentally sliced my thumb open today while trying to chop up an onion. It was a really sharp knife, and it went sort of deep, into the pad of my thumb.
I proceeded to wash it out with some soap and water and let it bleed. and, knowing a thing or 3 about this kind of thing, i knew it would be best to irrigate the heck out of it. I started to do this by spraying water directly into the cut, and quickly came to the realization that I will always anesthetize a person before irrigating.
it did not feel good.
i did have some suture, which might have been a little overkill, but i also had some krazy glue.
i must say, the krazy glue worked quite nicely. it's the poor man's dermabond.
cn
I proceeded to wash it out with some soap and water and let it bleed. and, knowing a thing or 3 about this kind of thing, i knew it would be best to irrigate the heck out of it. I started to do this by spraying water directly into the cut, and quickly came to the realization that I will always anesthetize a person before irrigating.
it did not feel good.
i did have some suture, which might have been a little overkill, but i also had some krazy glue.
i must say, the krazy glue worked quite nicely. it's the poor man's dermabond.
cn
Tuesday, December 9, 2008
Where it's at...I got two turn tables and a dictaphone.
I can remember, way back when, in a far off land that they call Ohio... a land of farms, amusement parks, people with unusually southern accents; a swing state... I can remember at this first rotation of mine hearing a doctor dictate so fast, that he sounded like the guy from the old micro-machine commercials. If you were a baby of the 80's... you know what I mean. If you weren't, or don't for some reason, youtube it here...
http://www.youtube.com/watch?v=mlRgbU3ZJ5g
I was quite amazed, anyhow.
I can remember even further back, having to muddle my way through a number of dictations for school. It was painful, even with a cheat sheet. I could not believe that this would actually save time... and I certainly felt a little bit weird about the whole thing. It's more awkward than you'd think, Captain Kirk-ing your way through a patient encounter.
"Beeedle-dooodle-dee! Captain's log, star date 23.9, rounded off to... the nearest decimal point....." I have picked up this little gray device, and, started speaking into it... really fast, disregarding all human contact, or other occurrences in the room.
Weird.
Well....... that's what I thought at first.
But it didn't take more than a day for me to love it.
What's this? No more hand writing SOAP notes!?!? No gigantic H7P for a well child check?
Awesome.
Stellar.
Fantastic.
Fantasmagorical!
Don't call me captain kirk... but you can call me Captain Nerd. I don't care, dictating is sweet.
CN
http://www.youtube.com/watch?v=mlRgbU3ZJ5g
I was quite amazed, anyhow.
I can remember even further back, having to muddle my way through a number of dictations for school. It was painful, even with a cheat sheet. I could not believe that this would actually save time... and I certainly felt a little bit weird about the whole thing. It's more awkward than you'd think, Captain Kirk-ing your way through a patient encounter.
"Beeedle-dooodle-dee! Captain's log, star date 23.9, rounded off to... the nearest decimal point....." I have picked up this little gray device, and, started speaking into it... really fast, disregarding all human contact, or other occurrences in the room.
Weird.
Well....... that's what I thought at first.
But it didn't take more than a day for me to love it.
What's this? No more hand writing SOAP notes!?!? No gigantic H7P for a well child check?
Awesome.
Stellar.
Fantastic.
Fantasmagorical!
Don't call me captain kirk... but you can call me Captain Nerd. I don't care, dictating is sweet.
CN
Friday, November 28, 2008
broken boys and ala carte healthcare
I thought that I was in Pediatrics, and done with Trauma. In fact, I'm pretty sure I just got done with my 6 week stint at Legacy Emanuel Trauma. I shouldn't be seeing broken bones, at least acutely, right? I should be dealing with well child checks, runny noses, and maybe dealing with asthma.
maybe not...
a couple of days ago, I stitched up the toe of a girl who managed to slice it on a mirror. I don't know if she saw her reflection, and like a young kitten, not knowing it was her in the mirror, freaked out.... hissed and batted at it like a flurry of right and left crosses, then somehow in the chaos sliced her toe.
or maybe she was practicing her karate kicks in the mirror, and got a little too close. in any case, I stitched her up.
And on the same day, I stitched up another kiddo's knee after a horrible recess time football accident. It was gruesome.... after three sutures, I realized we were in the clear, and we wouldn't have to amputate.
He was thankful.
Then, just this Monday I saw a 17 year old guy who was in an MVC, going about 30, went into a ditch. He went to the ER that night, Saturday, and got worked up and sent home. They told him to follow up with his PCP on Monday. They gave him a clean bill of health after, what I can gather, a few x-rays. He said that everything came back negative.
He still had low back pain, and noticed a bump on his head. He didn't lose consciousness, nor did he remember smacking his head. He was belted, and there wasn't too much damage to the car.
He didn't have any pain other than in his lower back... he moved around the room slowly and deliberately. He had a limited range of motion as I watched him move.
At Emanuel, they would always feel the spine before sliding the folks into the CT scanner, looking for step-offs and other deformities of the spine, as well as trying to illicit any pain response from the patient. These things being clues for a fracture. What you really look for, as far as the pain response is concerned, is tenderness on the bone, not in the muscles, but right on the bone.
At Emanuel, the surgical resident or the trauma PA did this... not me. So I didn't feel the patient react to pushing on their back, but I saw it.
I've done plenty of back pain exams now, in the ER and in clinic, and that's something you always check for.... that spinal tenderness. I've never had a patient react in such a way that I've been concerned that they have a broken back. Even the whiners.... it's just never been impressive.
"Does it hurt when I push here?"
"OHHHHH... uhhhhh, ahhhhh..... yeaaaa...."
"How about here?"
"Ehhhhhhhhhhh, yes." they'll groan.
No real reaction.
But this kid..... I have him sitting on the exam table and start pushing on his spine.... around L1... working my way down.
"Tell me if it hurts anywhere."
As I'm pushing, and working my way down his spine, I get to about L4, and he doesn't have to say a word... I push, and he JUMPS away from me. He moved faster than he had the entire time he'd been in there with me. I had pushed right on the spinous process of L4 and he was through the roof.
Anywhere else I pressed didn't bother him.... The muscles surrounding L4, the other spinous processes... nothing. No pain, no reaction.
ooooops.
"So, in the ER, did they do any CT's? You know, where you lay down on a table and they slide you into what looks like a huge doughnut?"
"Nope. They did X-rays."
"Well, you're gunna get one today."
He does... and the results came back via phone call from the radiologist.
L4 compression fracture with no posterior involvement (which is good) but with some anterior wedging/displacement.
It's basically stable, and there's not really any worry for this type of fracture paralyzing this kid. But it still warrants a spine-guy consult. Which we get all set up for him.
another little kiddo, well, about 11 years old, strolled in around the same time. He fell playing basketball, and hurt his arm... a quick x-ray later, we found that he had a torus fracture. we splinted him, then sent him off, only to come back in a week so we can cast him up once the swelling dissipates.
so, i've discovered that pediatrics can be more interesting, and varied, than i thought. i should have realized that kids tend to get hurt.
some kids that come in however, are not hurt, but act like it.
we had a teenage girl come in with her mom. She had been seen in the pediatric night clinic... (like urgent care, for kids) and was diagnosed with a sinus infection. she was given antibiotics and sent home. though, at the clinic, she and her mom were asking for an IV.
"I know my kids, they crash fast. and this one, she'll perk right up when she gets filled up. I mean, I know they do it for athletes, it's not a big deal. She did this the last time too, and Lisa gave her an IV, and she popped right back up! We asked for an IV last night, but they wouldn't give her one."
I'm thinking, as she's saying this, "she does NOT need an IV. that's just a waste of time, money and resources. It's an unnecessary risk (albeit a small one) for a placebo effect, and to appease the mother and child. This is NOT a McDonald's... you can't just order what you want!"
Or, i guess you can.
i should have known... well i did know. but it bothers me.
So I present the patient to the preceptor and say that they came in with the hopes of getting an IV, anything less than that will leave them upset. So, we bolus the girl with 1 Liter of NS. the NON-dehydrated girl.... and all was well in their world. It's amazing how a liter of salt water can make a sinus infection better. i guess i should have checked UpToDate... it's the preferred treatment, after all!
well, i've made a short story long, but.... turns out, i like peds more than i thought i would. even despite some of the silliness that is made-to-order medicine. That's just the way it is, in every field. It's not Doctor knows best, it's, "what can I do for you today? no matter if it's unwise, dangerous or just silly, it's your care! let's do it!"
In my practice, I won't fold so easily, I won't enable this kind of behavior. But, I'm just a student in a 6 week rotation. I'm not out to change a practice. I'm just out to practice.
cn
maybe not...
a couple of days ago, I stitched up the toe of a girl who managed to slice it on a mirror. I don't know if she saw her reflection, and like a young kitten, not knowing it was her in the mirror, freaked out.... hissed and batted at it like a flurry of right and left crosses, then somehow in the chaos sliced her toe.
or maybe she was practicing her karate kicks in the mirror, and got a little too close. in any case, I stitched her up.
And on the same day, I stitched up another kiddo's knee after a horrible recess time football accident. It was gruesome.... after three sutures, I realized we were in the clear, and we wouldn't have to amputate.
He was thankful.
Then, just this Monday I saw a 17 year old guy who was in an MVC, going about 30, went into a ditch. He went to the ER that night, Saturday, and got worked up and sent home. They told him to follow up with his PCP on Monday. They gave him a clean bill of health after, what I can gather, a few x-rays. He said that everything came back negative.
He still had low back pain, and noticed a bump on his head. He didn't lose consciousness, nor did he remember smacking his head. He was belted, and there wasn't too much damage to the car.
He didn't have any pain other than in his lower back... he moved around the room slowly and deliberately. He had a limited range of motion as I watched him move.
At Emanuel, they would always feel the spine before sliding the folks into the CT scanner, looking for step-offs and other deformities of the spine, as well as trying to illicit any pain response from the patient. These things being clues for a fracture. What you really look for, as far as the pain response is concerned, is tenderness on the bone, not in the muscles, but right on the bone.
At Emanuel, the surgical resident or the trauma PA did this... not me. So I didn't feel the patient react to pushing on their back, but I saw it.
I've done plenty of back pain exams now, in the ER and in clinic, and that's something you always check for.... that spinal tenderness. I've never had a patient react in such a way that I've been concerned that they have a broken back. Even the whiners.... it's just never been impressive.
"Does it hurt when I push here?"
"OHHHHH... uhhhhh, ahhhhh..... yeaaaa...."
"How about here?"
"Ehhhhhhhhhhh, yes." they'll groan.
No real reaction.
But this kid..... I have him sitting on the exam table and start pushing on his spine.... around L1... working my way down.
"Tell me if it hurts anywhere."
As I'm pushing, and working my way down his spine, I get to about L4, and he doesn't have to say a word... I push, and he JUMPS away from me. He moved faster than he had the entire time he'd been in there with me. I had pushed right on the spinous process of L4 and he was through the roof.
Anywhere else I pressed didn't bother him.... The muscles surrounding L4, the other spinous processes... nothing. No pain, no reaction.
ooooops.
"So, in the ER, did they do any CT's? You know, where you lay down on a table and they slide you into what looks like a huge doughnut?"
"Nope. They did X-rays."
"Well, you're gunna get one today."
He does... and the results came back via phone call from the radiologist.
L4 compression fracture with no posterior involvement (which is good) but with some anterior wedging/displacement.
It's basically stable, and there's not really any worry for this type of fracture paralyzing this kid. But it still warrants a spine-guy consult. Which we get all set up for him.
another little kiddo, well, about 11 years old, strolled in around the same time. He fell playing basketball, and hurt his arm... a quick x-ray later, we found that he had a torus fracture. we splinted him, then sent him off, only to come back in a week so we can cast him up once the swelling dissipates.
so, i've discovered that pediatrics can be more interesting, and varied, than i thought. i should have realized that kids tend to get hurt.
some kids that come in however, are not hurt, but act like it.
we had a teenage girl come in with her mom. She had been seen in the pediatric night clinic... (like urgent care, for kids) and was diagnosed with a sinus infection. she was given antibiotics and sent home. though, at the clinic, she and her mom were asking for an IV.
"I know my kids, they crash fast. and this one, she'll perk right up when she gets filled up. I mean, I know they do it for athletes, it's not a big deal. She did this the last time too, and Lisa gave her an IV, and she popped right back up! We asked for an IV last night, but they wouldn't give her one."
I'm thinking, as she's saying this, "she does NOT need an IV. that's just a waste of time, money and resources. It's an unnecessary risk (albeit a small one) for a placebo effect, and to appease the mother and child. This is NOT a McDonald's... you can't just order what you want!"
Or, i guess you can.
i should have known... well i did know. but it bothers me.
So I present the patient to the preceptor and say that they came in with the hopes of getting an IV, anything less than that will leave them upset. So, we bolus the girl with 1 Liter of NS. the NON-dehydrated girl.... and all was well in their world. It's amazing how a liter of salt water can make a sinus infection better. i guess i should have checked UpToDate... it's the preferred treatment, after all!
well, i've made a short story long, but.... turns out, i like peds more than i thought i would. even despite some of the silliness that is made-to-order medicine. That's just the way it is, in every field. It's not Doctor knows best, it's, "what can I do for you today? no matter if it's unwise, dangerous or just silly, it's your care! let's do it!"
In my practice, I won't fold so easily, I won't enable this kind of behavior. But, I'm just a student in a 6 week rotation. I'm not out to change a practice. I'm just out to practice.
cn
Saturday, November 22, 2008
catlike speed and reflexes...
A naked baby is a dangerous baby. The business end is ready to blow at any time. It's simply frightening to see a diaperless baby for any length of time. When I do well child exams, I make sure to be quick when it comes to diaperless baby time. I'd rather not get pooped or peed on, if at all possible.
I am constantly reminded of the fragility of my non-poop-covered clothes. In pushing on a the belly of a little 2 month old the other day, I created such an uproar inside her, that a gurgle turned into a largre rumble and a quite adult sized fart.
Yes, we all had a good laugh, mom, myself and the child. but the consequenses would have been dire had she not been wearing that huggies. I was right in the line of fire.
But I'm really only fooling myself if I think I'm going to make it out unscathed. I've already been soiled in other rotations, and in this one. So what I should really be practicing (other than my body-washing technique) is my speed and reflexes.
Anticipate that the little baby boy is going to try pee on you when the flippin' thing is aiming right at you like a little flesh colored fire hose. (with seemingly the same amount of power. It could definetely clear a rowdy crowd nearly as well as the conventional fire hose.)
I need to know that blank look of confusion and anticipation that appears on the face of a snot covered three year old just before they sneeze right in your face. Cover up, be damned!
I need to be like Neo, in The Matrix, time needs to slow down, just a bit, for me. I need to recognize the signs of impending disgusting, and maneuver through the air in such a way to avoid all the contaminated fluid flying my way.
So here I come, with my catlike speed an reflexes, I'm betting this kid has strep, but to be sure I need to shove that horrible, long q-tip down his throat and make him gag.
I should get a face shield... like that of a fire-fighter.
I don't.
"Hey there you little germ monger... I"m gunna cram this thing down your throat, and it's gunna make you gag... I know, I know, it sucks. I HATED this as a kid, but it's quick, and then it's all done. Just try not to barf on me."
Now I don't say this, in so many words, but close. I'm definetely thinking it.
In goes the q-tip, and here comes the gag.... and an instantaneous cough... I feel my face peppered with spit.
crap.
shoulda worn the fire-fighter helmet.
4 mintues later, I find out that the cough shrapnal was indeed teeming with strep.
excellent.
I had already washed off my face, and hands.... but, alas, it was too late. the next day... with my sinuses plugged, sore throat, and headache, I headed back for more.
you got me, kid, you got me. if it wasn't you, it was one of the other 20 something i see per day. but you know what... I like it.
I just need to work on my matrix moves. I need to be more like Neo, and less like Chris Farley in 'Tommy Boy'.
"I was checking the a ... specs on the end line.... for the rotary...... girder. I'm retarded."
http://www.youtube.com/watch?v=K9mBn9bMB-g
I am constantly reminded of the fragility of my non-poop-covered clothes. In pushing on a the belly of a little 2 month old the other day, I created such an uproar inside her, that a gurgle turned into a largre rumble and a quite adult sized fart.
Yes, we all had a good laugh, mom, myself and the child. but the consequenses would have been dire had she not been wearing that huggies. I was right in the line of fire.
But I'm really only fooling myself if I think I'm going to make it out unscathed. I've already been soiled in other rotations, and in this one. So what I should really be practicing (other than my body-washing technique) is my speed and reflexes.
Anticipate that the little baby boy is going to try pee on you when the flippin' thing is aiming right at you like a little flesh colored fire hose. (with seemingly the same amount of power. It could definetely clear a rowdy crowd nearly as well as the conventional fire hose.)
I need to know that blank look of confusion and anticipation that appears on the face of a snot covered three year old just before they sneeze right in your face. Cover up, be damned!
I need to be like Neo, in The Matrix, time needs to slow down, just a bit, for me. I need to recognize the signs of impending disgusting, and maneuver through the air in such a way to avoid all the contaminated fluid flying my way.
So here I come, with my catlike speed an reflexes, I'm betting this kid has strep, but to be sure I need to shove that horrible, long q-tip down his throat and make him gag.
I should get a face shield... like that of a fire-fighter.
I don't.
"Hey there you little germ monger... I"m gunna cram this thing down your throat, and it's gunna make you gag... I know, I know, it sucks. I HATED this as a kid, but it's quick, and then it's all done. Just try not to barf on me."
Now I don't say this, in so many words, but close. I'm definetely thinking it.
In goes the q-tip, and here comes the gag.... and an instantaneous cough... I feel my face peppered with spit.
crap.
shoulda worn the fire-fighter helmet.
4 mintues later, I find out that the cough shrapnal was indeed teeming with strep.
excellent.
I had already washed off my face, and hands.... but, alas, it was too late. the next day... with my sinuses plugged, sore throat, and headache, I headed back for more.
you got me, kid, you got me. if it wasn't you, it was one of the other 20 something i see per day. but you know what... I like it.
I just need to work on my matrix moves. I need to be more like Neo, and less like Chris Farley in 'Tommy Boy'.
"I was checking the a ... specs on the end line.... for the rotary...... girder. I'm retarded."
http://www.youtube.com/watch?v=K9mBn9bMB-g
Thursday, October 9, 2008
no use for a name
day off tomorrow... gunna enjoy it.
also, working trauma makes me think of all the ways i could get hurt, and how incredibly lucky i am to NOT be hurt.
so, while i'll be having fun tomorrow... gunna step correctly.
later, monkeys.
cn
also, working trauma makes me think of all the ways i could get hurt, and how incredibly lucky i am to NOT be hurt.
so, while i'll be having fun tomorrow... gunna step correctly.
later, monkeys.
cn
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