Found Buried in BBC News

Too bad only 1/100000th of the people who have heard there is a "link between autism and MMR vaccine" will actually hear Wakefield conducted unethical studies on only 12 subjects and published false information. Oh well, I guess if Jenny McCarthy says its true it must be (apparently to pose for Playboy you have to have a PhD in Immunology).

On Friday the verdict came out about his conduct and the General Medical Council is now considering "whether Dr Wakefield's behaviour, and that of his colleagues, amounts to serious professional misconduct and then if any sanctions should be imposed, such as striking them off the medical register."

Photo Andrew Zuckerman and Wired Article

When It Isn't A Stranger on the Table

This past week our case has been a 61 year old gentleman who presents to the A & E (Accident and Emergency here in Europe) with crushing chest pain. Naturally we've been working through the histology of heart muscle, the conduction system, the cardiac circulation. There have been graphs of enzyme releases and numbers relating to action potentials scribbled down. Pharmacology and receptors discussed ad nauseum.

I couldn't put my finger on it for a few days, but I felt out of touch with the lectures and the PBL discussions. Strange for me because the emergency nurse still living inside me loves cardiac presentations and interventions.

Then it dawned on me. My dad died of a massive heart attack. 

I know it is probably immediately obvious to most people why I was a little dissociated from the learning this week. But it truly was a surprise for me because we were examining this presentation at such a microscopic level that I truly didn't see the forest for the trees.

So to remind myself, and to all the academics out there that there is a human, a soul, a spirit that gives breath and life to the myocytes we spend so much time looking at slides of...I am reposting the story of my dad and his final heart attack. Because it is something we all need to remember, for every troponin level we're anxiously waiting for so we can turf the patient to CCU or home, there is a family that is also anxiously awaiting those results. 

---

When my dad laughed, it was a borderline giggle. As manly a giggle as you can imagine, but a giggle nonetheless. He really let loose though, usually turning his head to the side and scrunching up his shoulders while his whole body shook.

In a word, he was a 'character'. A prankster. Not mean or hurtful pranks, but anything he could get a good story from.

He would perform last-minute pranks, ones that involved no prep or props. Like sticking his big toe on the back of the scale when my mom was weighing herself, or telling the kindergarten kids that rode his bus that there were "two Friday's this week" so he'd be there in the morning to pick them up. My sisters current event for social studies class one day was that the "Pope had turned Protestant" thanks to my dad. He hid pork chops in the pockets of his friends coveralls on a Friday afternoon so that come Monday when they got back to work there'd have a nice surprise with their morning coffee.

When my uncle was particularly proud of his new television set my dad went out and bought a universal remote which he'd bring to their house and use to turn the volume up and down at infuriating intervals convincing my easily flustered uncle that he'd made a dud purchase.

One of his more elaborate stunts was when he surprised my mother on the 'throne' and snapped a picture of her, developed the photo and then cut it to fit in her wallet. I was at the supermarket with her the day she pulled her credit card out and with it came flying the photo of her on the toilet, landing right on the scan pad.

He loved it when I'd get engrossed in something scary on t.v. He'd sneak behind the couch and just as Hannibal Lecter was closing in he'd startle me with a "Haarr!" while I came a foot off the cushions, screaming and yelling "DAD!"

One Monday morning my dad's alarm clock went off for work and he didn't shut it off. His girlfriend thought it was odd because he was always up with the first crackles of the morning news. She turned over to ask him why he wasn't getting up and discovered that he was dead.

I was starting my first day of a community practicum in nursing school that day. I had been dreaming that I was at this odd wrecking yard which was more of a wrecking yard for people, not cars. There were these large looming pieces of ramshackle machinery and I was getting a tour. Just as the tour guide got to a group of Dachau-esque ovens and said "this is the crematorium" the phone rang, waking me up. I was shaking out the images from my disturbing dream but felt something else must be wrong because the phone never rang this early in the morning.

I picked it up to my mothers voice on the other end. She asked me if Benje was with me, I said yes. She said, "honey, your father died today, I'm coming to get you to take you to his place".

I don't remember many clear details from that day. But a few things are still with me. Sitting at my dad's kitchen table with my aunties and his girlfriend, my dog Cubby moping and whining around the house. A petite brunette who worked for victim services gave me some pamphlets and I remember thinking "what a shitty job you've got lady".

I had a professor in university who was a beautiful soul that had seen many tragedies in her time as an ER nurse in Toronto and Edmonton. On a shift when one of my fellow students saw her elderly patient die, Madeline sat us all down and told us how she helped families manage grief. Again and again she stressed that we ought to encourage families to make physical contact with the deceased, show them it is OK to touch their loved ones hand, or stroke their face. Her belief was it helped make the abstract concept of death more concrete. It gave tangible proof to push denial aside and let the beginnings of grieving grow.

The funeral home was at the end of a quiet street in the small town near his acreage. We were sitting in the funeral directors office discussing the upcoming autopsy and the cost and logistics of transporting a body back for viewing. I was tuning in and out. Wait, the medical examiners office? I had been to autopsies there. I hurried that thought out of my mind.

He informed me that I could save 600$ if they could have his ashes FedEx'ed to the church after the autopsy, rather than transporting the body. I howled with laughter, "Fed Ex!!??" I thought that was hilarious . Who knew you could have your ashes sent by priority courier? I was chuckling still when he answered me with a most stern, "yes". I glanced around the room and seeing that I was the only one who found this funny I stifled myself with a "hmfpf" and stared down at the balled up kleenex in my hand. When the funeral director finally asked me if I'd like to see my father I nodded and followed a few feet behind as he led me to the back of the room which served as a chapel.

I stood at the threshold. The length between me and the table which supported my fathers body seemed to stretch out to an impossible distance. The floor was gray linoleum and empty but for the body at the opposite end. To my left light streamed in through the dusty venetian blinds that were half open. On the right were brown padded chairs with metal legs stacked on top of one another.

The funeral director said he would step out to give me some privacy.

I just stood there staring straight ahead. I wasn't sure what to do. I wasn't sure if my legs could get me to the table. One side of my head was yelling "No! No! No! No!" and the other was hearing Madeline's voice telling us about encouraging families to have contact with the body. No way did I want some maladjusted grieving, stunted acceptance to befall me.

I edged forward and arrived at his side. His face was bluish gray. A small trickle of blood was dried in his ear. His mouth was hanging slack and he had enough stubble to warrant a shave. The white blanket was pulled up to his chin. It wasn't my father. The man who was my father had a mischievous twinkle, and was quick to laugh. This thing in front of me was an abandoned carcass. An evacuated shell. I saw that with his soul, his essence gone that he really had very little to do with his body. His skin and bones and eyes and mouth were just part of a complex interface required by his spirit to interact with the rest of us (who are also trapped by the same limiting coveralls). I knew that he had not come to an end  because having a heart stop beating could not cause such a dramatic metamorphosis to a vessel.

I thought for a moment that he was probably watching me, maybe circling above me somehow. I slowly reached my hand forward, intent on touching his shoulder. As I watched my hand get closer the moment of contact occurred. At that exact second a car horn blasted outside the windows. I jumped into the air and felt the rush of adrenaline hit my fingertips.

And with that I was laughing and waving my hand in the air.

"Hey Dad! Nice one. You got me!!"

So dad, if you're reading blogs out there in the ionosphere, this ones for you.

Part 2 of Another Day on Call in the Arctic

Next in line to see the nurse on call...Pommer, the Pomeranian.

We finally breathed a collective sigh of relief as the unstable cardiac patient was loaded onto the medevac plane.

We got the call that there was a lady with a dog who had a broken leg. Apparently she had called the RCMP first but they directed her to the health center. I was on-call so agreed to see the pooch. We're not really supposed to treat animals but as the nearest vet is 4h away by plane we usually bend the rules and help out if we can.

Pommer was a rust colored fur-ball of a puppy. An adorable 4 month old who had apparently been 'dropped' by the chubby, flat affected, 8 year old---er---since when did dogs break their legs from being dropped 3 feet above the ground?

Anyway, the dog seemed settled enough in the mothers arms but with even the slightest movement the yelps of pain elicited were so ear and heart piercing that we could hardly bear it. Our attempts at x-ray had been traumatizing for everyone involved. Thus the decision was made to try and medicate and splint the poor creature.

So I called Dr. P in Whitehorse, a vet who gives over-the-phone advice and he talked me through how to create a muzzle out of kling gauze (so as to not get bitten) and how to landmark for an intramuscular injection of demerol. And so the splint was made with the bendable metal we fashion finger splints, gauze, and kling. We had to get creative with the narcotic sign out sheet that day...Did you know that dogs have radius' and ulnas? I had to laugh at the learning curve of the evening. It perfectly depicted life in the North. One minute you're giving I.V amiodarone to an unstable cardiac patient and the next you're making leg splints for a puppy.

All in a day's work.

P.S Doctor D has graciously nominated me for a med-student blogger award! Head on over and cast your vote in my favor of course.

Memory Stick Only Useful When You Remember Where you Put It

I lost my memory stick which contained ALL of my notes, powerpoints, anatomy slides, and review sheets from last semester.

This distresses me greatly.

For some reason I have also lost my studying mojo. Which is weird because I *love* cardiac and our last two cases have been CVS related ones! I don't know why but I just cannot concentrate these past few days.

Also, last week we had a presentation from CARMS which is the residency placement organization for Canada. Basically as international medical graduates (IMG's) we are hooped for residencies, especially if we want to go to BC, AB, or QC. Oh right, the three provinces I actually wanted to do my residency in. FML.

More on that whole soul crushing presentation later.

Word of advice to those Canadians who REALLY want to go to medical school but are tired to trying to get in in Canada. KEEP TRYING. Turns out being an IMG=leper in Canadian system.

Off to start my USMLE prep.

P.S Hey Canada (especially you BC, QC, and AB) maybe you should stop complaining about the MD shortage now because clearly if you were THAT desperate for doctors you wouldn't make Irish medical graduates work at Starbucks for a year between completing medical school and starting residencies. Thanks.

Diagnosis Wenckebach

I was told by a classmate "You're gonna need to beat a bear to death in order to replenish your cool-levels after that" when I posted this on facebook.

What can I say? It's my OG Alma Mater yo!

Awkward...and Inappropriate

So last week we had a large research forum at school where local scientists came to discuss their work and the applications it would have to medicine.

For the most part it was a 'how to get yourself published in 8 weeks if you apply for this research funding and work with one of these dudes/dudettes'. So for the Canadians who are going home over the summer and don't qualify for the grants/opportunities it was just a chance to hear some of the exciting things going on in Irish research.

The keynote of the day came late, an address by Dr. Robert Gallo, a world famous MD/researcher who is (arguably) credited for co-discovering the HIV virus and it's link to AIDS. The man is also the most cited living researcher and has been published in over 1500 scientific journals. He gave a very funny, insightful, informative, and humble presentation on his work and where HIV research is heading in the 21st century.

I was so pleased to have the opportunity to hear him speak.

Then they opened up the floor to questions.

I noticed in the crowd many of the researchers from the day, fellow med students, medical school faculty. Actually was looking forward to hearing what some folks might put to him for questions...I mean he is one of the great living minds in the area of medical research.

Question 1 (clean-cut dude with GAP sweater and jeans stands up):

"WITH NO ADVANCEMENTS TOWARD A CURE FOR AIDS AND NO OTHER PROVEN MEDICAL ADVANCEMENTS WHY ARE YOU PEOPLE STILL DOING TESTING ON ANIMALS??? HOW MANY ANIMALS HAVE TO DIE AND HOW MANY BILLIONS OF DOLLARS HAVE TO BE SPENT BEFORE YOU REALIZE THAT IT IS FUTILE AND ONLY HARMFUL TO ANIMALS WITH NO GAIN TO HUMANS OR MEDICAL SCIENCE???"

It is in caps for a reason. He wasn't yelling at the TOP of his lungs but he was speaking so loudly and forcefully that his JVP was measurable from across the lecture theater.


(Heads in crowd shaking...looks of disbelief...I see blood drain from Dean of Medicine's face).

Now if I wasn't completely won over by Dr. Gallo before this part, he got me with his answer. His response was gracious, and even incorporated some light humor into the tense setting that overtook the room. He talked about the restrictions of human drug testing, the FDA, the expense of using animal subjects...etc. And how, if dood knew any ways around it and could present him with a feasible alternative, he'd gladly and willingly give up animal testing. Class act.

Pale and shaken Dean takes mic and asks for another question...

Question 2 (Older dude, with long skull and crossbone headband, heavy peri-orbital edema, white t-shirt):

"So I have this friend who has a CD4 count of 700 and an undetectable viral load....and he's having unprotected sex...with a woman...and he hasn't told her that he's HIV positive...what do you think about that? Is she at risk for getting AIDS?......oh and I should probably mention that she is pregnant with his child...is the baby at risk of catching AIDS? And should she breastfeed? Did I mention, his CD4 count is 700 and viral load is undetectable? What would be your advice?"

Just when you thought question period couldn't get any worse. It clearly had.

Dean of Medicine now looks like he's on verge of collapse as all blood has completely left the upper half of his body. Eyes are darting for burning fireplace or woodchipper to toss microphone into.

Again Dr. Gallo took the time to respond thoroughly to the question, as if he had been the guys doctor for the past 10 years. Oh sorry, the guys "friends'" doctor.  Riiiiiighhhhhhhht.

Listen up people.

If you're having some questions to do with your HIV status, your lowly moral reasoning at not informing your partner that you *may* be exposing him/her to a deadly disease, and your unborn childs'  future----please talk to your GP, call the nurses line, go to a STI clinic, but don't come and ask Dr. Gallo if your 'friend' should tell his girlfriend/mother-of-his-unborn-child that he's HIV positive.

Not appropriate.

It's like asking Marie Curie if you should have a follow-up x-ray on your scaphoid fracture or James Shapiro how many units of NPH you should take if your blood glucose is running a little higher than usual. 

Which brings me to another thing that gives me a rash...medical people are many things, but one thing that we are not--is naive.

If you start citing your "friends" lab values the gig is up. We know who you are talking about.

If you tell the triage nurse that you were walking down the street, minding your own business and a shotgun went off on your kneecap--oh and that it was not a gang related incident---we are still going to have to notify police.

If you say you slipped in the shower and your hand landed against the wall (which happened to be cement) clenched in a fist to "catch yourself" we are going to know you got in a fight. That's why it's called a "boxers fracture".

We know that the reason your tox screen came back positive for cocaine wasn't because the taxi driver sprinkled cocaine in the cigarette he gave you, even though you're *sure* that is the only way it could have gotten in your bloodstream.

Don't treat us like naive fools, because most of us aren't.

Thank you. (Steps off soapbox).

My Politically Incorrect Medical Education Part 2

During the research forum yesterday one of the presenters was discussing his research into 'causes of falls' in the elderly.

"What causes the elderly to fall at home is not what most people think...it's not loose carpet, or loose buttons, loose cats, or loose women....it's a variety of causes, one being orthostatic hypotension."

***

And today during clinical skills as my instructor was searching for my pedal pulse...I apologized for him having to get so close to my pegs as he demoed 'inspecting' my feet for ulcers, etc. and he replied,

"Oh don't worry honey, I'd take feet over vaginas or mamms any day of the week"

My response,

"Jeazus!"*

*Proof that this Irish education is starting to rub off on me. 

*Facepalm*

Every week we get a new patient case study in PBL. And we meet twice a week to receive new info about this patient. At the beginning of each session we start with a summary of the patients condition, test results, etc. A "report" if you will.

I usually do not volunteer to do this task because I have been giving report on patients in the ED for, oh, 6 years now. I am comfortable with it, I can handle giving report on 20 odd patients at a time. It really isn't a challenge to remember 1 patients presenting complaint, lab values, diagnostic results, care plan, etc. I figure the other folks in my group ought to have the chance to practice this VERY IMPORTANT skill.

Last week no one was volunteering and I couldn't bear the silence any longer so I said I'd do it. Bah. No biggie. This morning I thought--heck, I'll actually review the case and look at all the lab results and stuff so I can wow them with my ability to remember the minute details like how acidotic he was.

I rattled off the report, leaving no stone unturned. X-ray, labs, echo, vitals, medical history, family history, work history...how many pack years...his units of ETOH daily...everything. Pleased with myself, I finished.

My tutor added,

"And we also treated him didn't we? With some things like oxygen...some drugs? Care to mention those???"

*FACEPALM*.

Yeah. Yeah we did.

I'm an idiot.

I guess it was more a report on the status of my over-inflated ego.

Another Day On Call in the Arctic

I miss working. I can't believe I just wrote that. It's true though. Feeling nostalgic today I was reading through my journal from a few years ago when I was working in a remote Inuit community in the Western Arctic. It makes me antsy to get back into the trenches. And so, another installment from Ohtanninbound (my original blog)...

I actually helped save a man's life today.
Cut my finger trying to eat a muffin.
And watched some bad Canadian television.

It was so interesting to see the events of the day unfold in a dream-like sequence...I felt like I was watching it all from behind glass, yet so in it I could barely raise my head above the smell of benzoin. The benzoin was being used as a tacky assistant, since the EKG stickers were sliding off the patient as fast as we toweled him and applied them. The cold sweat seemed to travel down his body like a clear oil slick, removing all our feeble attempts at securing I.V's and electrodes to get a heart tracing. The benzoin's sap-like consistency anchored our only diagnostic tool.

A garbage bag curtain hid the unfolding ice storm as inside we swirled around our most diaphoretic, nauseated, hypotensive, peripherally shut down patient.

I had been assessing a young man's knee when Jane burst into my office. She can get a bit dramatic near the end of her stints so I wasn't fazed at first. "Uhh...I think I've got an M.I in my office." M.I is medspeak for myocardial infarction, a.k.a 'heart attack', a.k.a 'a jammer'. I asked my patient to hold tight. I love cardiac stuff. It's a throwback to my old ER stomping ground that was in the heart (pun intended) of the silver tsunami which is the West Coast. Cardiac emergencies are interesting, challenging, emergent. Emergent is a nice change from the doldrums of most ER care which revolves around abdominal pain, back pain, flus, colds, headaches, lacerations, psyche, and the odd trauma.

I happily left the twisted knee and went into the trauma room. There, slumped on the stretcher was a very distressed Inuit man. He was clutching the center of his chest with one arm and failing around, grasping at air with the other. He was moaning loudly and the sweat was literally flying off him. His tan skin had somehow managed to take on a ghastly gray/green tinge and I could immediately see that we were in for the long haul with this chap.

No cardiac monitors, defibrillators, no I.V pumps. I was used to these constraints in settlements but cardiac problems are so rare that normally I don't notice it. I wheeled the EKG machine to the bedside as our only means of 'cardiac monitoring' . He was in v-tach. This was glaringly obvious the second I fired on the EKG with help from Jane, who was starting I.V's and trying desperately to have the leads stick to his chest which was as slippery as the frozen ground outside.

A heart beating 240 times a minute is more like a fluttering wing than a pumping muscle. When this happens oxygenated blood does not get to the right places. Where the blood is not perfusing the starved cells begin to die. One place that doesn't get the supply it needs is the heart in these situations. And in these cases, minutes mean muscle.

It was bad. Maybe a pressure palpable at around 65 systolic. I was scared and excited and intrigued all at the same time. I was loving it.

I hate to admit to the morbid love of real emergency situations but really it is such a charge.
At one point I remember looking at him, curled in the fetal position with his sweaty hair plastered to his face, a shiny gray, and thinking to myself, "he is going to crash. He is going to crash and we have no electricity to do anything. He is going to crash. Are we going to tube him? Is he maintaining an airway?"

He was gulping for air despite the 10L NRB mask on and the nasal prongs at 4L. Gulping! And we couldn't get an o2 sat because his fingertips were giving up no information. The sat monitor could not read how much oxygen his red blood cells were carrying around...his capillary blood had packed up and moved north.

More north than we were.

I called the doctor at the hospital which was an hour away by plane (the only way in and out of the community). As usual the security guard/answering service put me on hold for a horrifyingly long time. By this time Lawrence, our only other nurse, had taken over the duty of watching the EKG machines 2x2 inch screen for any changes while Jane worked continuously to dry off and re-tape the electrodes as they slipped off.

I hung up the phone and called the emergency line again, this time telling the security guard that I needed the MD on call toute suite. A harried doc came on the line and I apologized for raising the alarm but told him he needed to initiate a medevac for an extremely unstable cardiac patient and I needed some orders for the impending code that was going to happen. He asked me to fax the EKG and get amiodarone into the patient as soon as possible, well, as soon as he got the EKG and could confirm my v-tach diagnosis. To take care about the administration and set the pump to make sure he got the right dose. Pump! I laughed. "No pumps around here bud, I'll be giving that drug in a syringe drop by drop over 10 minutes once the loading dose is in!"


Our secretary was with the patients wife in the coffee room, trying to keep her calm so I was fiddling around with the ridiculous fax machine while trying to draw up the amiodarone and double check the dosing at the same time. Jane and Lawrence had their hands full still trying to get a basic set of vitals on the guy. Finally the janitor walked by and I managed to snag him into sorting out the fax.

In a few long minutes the doc called back and told me he'd initiated the medevac and had received the EKG. I thanked him and hung up the phone.

The loading dose of the drug went in and I shook my head at the set up we were dealing with. An impending blizzard outside, no way to properly monitor the patient, and no way to deal with him if he coded. I felt like my hands had been tied behind my back while the crisis crescendoed.

I held the 60cc syringe in my hand while watching the clock (the only real technology in the room) and dribbled in the maintenance dose.

Then lo he suddenly said--'the pain is gone'. He let go of his chest and turned his head to me in surprise.

The dregs of the amiodarone were still going in by my hand. I ran to the other side of the stretcher and happily informed him, indeed the pain was gone because he was in a sinus rhythm. I must have thought, thank God or someone.

I know that then I must have exhaled completely for the first time since seeing him floating in his own juices on that emerg stretcher from the 1950's.

The time had warped. Despite the freezing rain and the blowing snow, the fog and the ceiling the plane landed and he was scooped (infuriatingly slowly!!!) by the paramedic and med student.

And off they flew, 6h after he'd driven himself to us.

Suddenly realizing that it had been too long since I'd had a chance to pee, eat, or drink water, I endeavored to change that. In the process of trying to quickly saw in half one of my 4 day old muffins the chopping knife slipped and gashed my left index finger.

That was annoying. It started bleeding and bleeding, I thought--there is no way i am getting sutures today...so I applied pressure, steristrips and a bandage. And was still annoyed. And will continue to be as the deep cut on my right index finger from climbing has only been freed from bandaids for 24h. Ugh. Oh well, I realize how pathetic a cut finger is compared to a jelly heart.

But I thank him and bless him. He gave us a rare satisfaction. The feeling that we actually did something really important that day. We worked as a team and even with our limited resources we actually saved a life. We didn't just look in throats and ears and give out septra for U.T.I's all day.

It also made me thankful that I had spent those hellish nights in the viper pit in my old emerg department. That's what all those countless cardiac cases were preparing me for.

I do hope he does well, was such a nice, funny, man. He joked with me about wanting to eat berries and that he was getting ready to 'run out' and pick some before the medivac crew arrived.

The wind is rattling my windows still and the power just went out. Thankfully he got out before the storm really hit.

Todays Quote from the Classroom

In our clinical skills lab the instructor was talking about signs of respiratory distress in babies.

"Since they can't tell you anything...you're basically practicing vet medicine".