Sunday, January 31, 2010

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

Saturday, January 30, 2010

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.

Friday, January 29, 2010

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.

Thursday, January 28, 2010

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.

Wednesday, January 27, 2010

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!

Monday, January 25, 2010

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):


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 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).

Thursday, January 21, 2010

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's not loose carpet, or loose buttons, loose cats, or loose'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,


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

Tuesday, January 19, 2010


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 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???"


Yeah. Yeah we did.

I'm an idiot.

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

Sunday, January 17, 2010

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 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.

Thursday, January 14, 2010

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're basically practicing vet medicine".

Wednesday, January 13, 2010

My Politically Incorrect Medical Education

Yesterday we had a lecture on EKG interpretation and the cardiologist giving the lecture was chatting about using the R-R interval to calculate heart rate. It went like this:

"Take 300 and divide it by the number of small squares between the R to R interval...that gives you the there are 2 squares between the R-R what is the HR...?"

-Everyone stares back in silence.

"150!!" he says exasperatedly.

"So look at this one...there are 3 squares between the R-R interval....what does that make the HR?"

-Silence again.

"JEAZUS! Are ye RETARDED? It's NOT that complicated!!"

I almost lost my sip of tea out the nose.

One of the many hilarious quirks of Ireland and Irish medical training. The consultants actually yell "JEAZUS", and call you "retarded" during lecture, and no one even blinks an eye.

Monday, January 11, 2010

Back to No-Life, Back to Reality

Tomorrow classes start again. Which is probably a good thing because I am spending waaaaaaay too much time in the highly entertaining blogosphere. I heart all you medbloggers.

Things will be busy, what with the resolutions and all.

Manfriend and I have decided that today will be a day of 'deep relaxation'. After pilates* we are donning  'relaxing pants' (a.k.a sweat pants).  Getting new mohair blanket out.

There will be tea drinking, book reading, movie watching. The last day of true indulgence.

Does it mean you are old when the above activities are considered 'true indulgence'???

--ABB suddenly flashes back to her reckless youth and shakes her head.--

Well my life expectancy got a little longer when I changed that definition I suppose.

*Update post pilates: the instructor actually taught the class to the entire Dirty Dancing soundtrack. It just doesn't seem right to be doing boat pose to "She's Like the Wind". I was giggling a lot. Couldn't help myself! And squats to "Yes!" I had to hold back from throwing some arms in. You just can't tease a girl with partial dance moves to that kind of music. I have a hard enough time not going into the side-step when I am running.

"She leads me to moonlight, only to burn me with the sun..."

Sunday, January 10, 2010

What I Learned About Doctors in Nursing School

 MD Girl* and Liana both were curious as to what we were taught about doctors/med students in nursing school, it was shaping up to be an irritatingly long comment from me so here is a post instead. I used bold so that you could skim through a 3 minute version of my answer the question. For those who are drinking your morning coffee and want a long winded between the bold.

I wish I could offer some very interesting, discussion promoting, insightful answer to that question but I honestly don't have one.

I really had to dig into the recesses of my mind to try and recall specific things that were said about physicians or medical students (formally) in any of my classes. There was a class that was a small group session with pharmacy, nursing, medical, O.T students, which Keet mentioned, but for some reason I had too many electives and they didn't make me take it. It was apparently supposed to highlight the different areas of expertise in the allied health fields, and teach everyone to play nice once they were in the professional sand box together. 

As Keet said in his response in the comments--it really depended on the instructor what was said and what was taught with regard to doctors and medical students. There wasn't what I would call a specific mantra in the curriculum that was repeatedly droned to us.

So instead I'll give you a brief sketch of the types of instructors and the lessons we were meant to learn from them...

Some instructors were from the days of yore when nurses stood up if a doctor entered the room. Those were the ones that implied that we never question anything, we perform our orders even if they seemed inappropriate, and never assume that we had gleaned any information in our extensive interactions with the patient which the doctor might have missed (and therefore not to bother HIM with such trivial matters). Med students also deserved a seat if we were in report together and they were standing. Oh, and we were meant to find all the doctors hilarious, charming, always appropriate, and a fountain of fascinating tales on everything from fly-fishing to changing the oil in their new Mercedes convertible. 

Other instructors were hellbent on providing ample examples of when they were right about something and the doctor/medstudent was wrong. These instructors anecdotes had the central theme of them saving the day with monotonous regularity and I usually mentally rolled my eyes when another health care homily started. These nurses had the clearly visible chip-on-shoulder approach to all physicians (and med students). They were also the ones that gave med students grief, just because they could.

The take home message that was drilled into my brain though was--do not develop a false sense of security just because you are not the one writing the orders. If a doc orders the wrong drug/dose and you give it--YOU are responsible. Ensure you always know what you are giving, the side effects, the intended therapeutic effects and your patients allergies. That nugget was a keeper and I still am very anal about medication administration--especially because so much of what we give in the ED is I.V push (i.e the fastest acting method to give a drug and quickest way to kill someone if you make a mistake).  I am still blown away when I am getting report and the patient is on a med I've never heard of and I ask--"Oh, what is that drug for?  What does it do?" and I get "Oh, I don't know" from the nurse who administered it.


But I digress.

Another type of instructor (and when I say that I mean clinical and/or lecturer) is the type that sees MD's/med students basically as a colleague. They told us that nurses and doctors were each their own profession but that we were supposed to work as a team. They got along with docs/students on the floors and encouraged us to use the medical students/doctors as a resource if we didn't understand something. They encouraged us to ask questions, confirm orders we thought were shaky, and to bring our patient concerns to the PCP/med student as we were the patients advocates.

Which brings me to the final camp--the slightly out of touch academic nurses who were now onto their post-docs in nursing. They were teaching us only because they had to round out their esoteric academic indulgences with some actual student interaction--as per their contract. These nurses hadn't had any clinical experience in over 20 years. They had spent their careers doing things like developing nursing theory and nursing diagnoses. Now usually I get a rash when I think back to those lectures and the subsequent papers I had to write because I think a lot of it is actually *not* clinically relevant and is really self-indulgent navel gazing.  But before I get a flood of comments--especially from you Keet---(hee) I will say that some of the models and theories are very well developed and very applicable: the patient centered care model, Orem's self care model are a couple that immediately spring to mind. But I swear if I hear the words "health as enabling consciousness" or "contrasending with possibles" I still break out in a cold sweat.

A lot of these instructors seemed to forget that physicians and medical students existed (or maybe they wanted to forget). You could have entire courses with these people and never hear those words. Partly because these women (yes they were all women so I can say that) were so very very focused on promoting nursing as a profession. Period. Thus their main thrust was expanding nurse theory, nursing diagnosis, nurse practitioner roles and nurse autonomy, so all of this had very little to do with the interaction of nurses and doctors. I don't mean to sound overly glib on this matter--I actually agree that nurses are professionals and should be seen as such. I also agree that many nurses would be amazing in expanded roles with increased autonomy. But that is not what all nurses want. And if we're going to be working in a hospital or clinic (no matter what the scope) I think *some* attention should be paid to what the roles  (R.N, nurse practitioner, L.P.N, medical student, resident, attending) mean and how we can maximize efficiency, patient care, and patient safety by working in harmony.

I hope that answered your question.

I am always happy to be spurned to think about these things, so thank you for the comments and questions.

*I thought that was a better abbreviation than 'Old Girl' because yeah, that isn't an overly apt moniker.   :-)

Friday, January 8, 2010

Somedays I Feel Like A Mole or Why I Went to Medical School

I always wondered what doctors really thought of nurses, or how nurses were portrayed to medical students.  I could never really get an answer I truly believed because none of my doctor friends would ever make disparaging comments about nurses around me (or if they did they'd preface it with some disclaimer so that I wouldn't be offended).

I saw how some doctors listened to nurses, I noticed how some would always do the opposite of anything a nurse suggested or would ignore any information a nurse brought to the table.

The dynamics were always very different too, depending on the department and location.

The first ED I worked in the docs and nurses got on fairly well as a general rule. There was banter between the two, you could clarify an order without attitude, you could ask 'why?' if you didn't understand the rationale for something being given to a patient. It was expected with urgent patients that the blood work, x-rays, and I.V's would be initiated by the nurse before the doc saw the patient and you had better run for cover if they weren't. It was a pleasant place to work, although I must admit I was nauseated and insomniac with fear the first 6 months (I was a new grad).

In my second/third ED the nurses and doctors barely even spoke to each other, except out of necessity. The doctors wrote orders, put them in a slot, the nurses picked them up and carried them out. R.N's wouldn't initiate any sort of treatment (other than I.V's) without an order. And with certain M.D's you wouldn't even do that because then they'd make some passive aggressive remark to the patient like, "I wasn't going to order an I.V and make you get a needle for no reason but the nurse decided you needed one".

The two camps never socialized together. 

On the wall in the hallway to the department were a bunch of historical photos and documents from the hospital when it was established over 100 years ago. One of the documents was a framed timetable of nursing duties which started off with "0630h--clean and mop doctors lounge and locker room".

I am sure that some of those docs wondered why the nurses weren't still doing that before report.

Then I started working up North where the nearest doctor was hundreds of kilometers away (by plane ride only) and my sole interaction with them was by phone or teleconference. I generally had a great working relationship with all these colleagues who I strangely never met but spoke on the phone with many times. When I needed a medevac they'd arrange it and find me a bed in the south--no questions asked. There was a great deal of trust and respect (for the most part) because many of the physicians who worked in the receiving hospitals had been to these remote communities and knew what we were up against; we could do chest and limb x-rays, HgB, WBC (using a microscope, counter, and half an hour of spare time), HCG, fetal fibronectin, and RBS. With only 1 exception of the 11 stations I worked in there was no defibrillator, no monitors, no I.V pumps, no rapid troponin machine, and no blood.  The new residents were told in no uncertain terms--if an outpost nurse calls you for a medevac--you arrange it.

My only major head-bang-into-concrete-because-it-feels-better-than-this-conversation moment was once when I called to arrange a non emergent transfer of a patient who clearly needed a cardiology consult in the south. I told the ED consultant that the patient had been having unstable angina for over a week and due to his past history of heart attack and hypertension I felt that keeping him in the high arctic (i.e 8 hours by plane to a major hospital and cath lab) was unsafe. He told me not to "use the word 'angina' because that was a diagnosis. And nurses don't make diagnoses."

After that I worked in a very busy ED which happened to be at the bottom of two very large mountains that skiers, snowboarders, monoborders, and telemarkers enjoyed--sometimes to the tune of over 20 000 people on a busy day. This was like a fairy tale ED. 80% of the patients were pretty healthy but had some acute injury which we were really good at dealing with. People came in, we fixed them or stabilized them, and they went away satisfied (for the most part). This is not usually the case in most emergency departments. The morale between the nurses, docs, and paramedics was very good. They had Christmas dinner together, stood up for each other at their weddings, skied together, biked together, raced together. I loved it there and knew it was a place of trust when one day I saw the orders for a fx humerus that read: analgesic.

The paramedics, nurses, and docs were all very good at orthopedic trauma (to the extent of which I didn't appreciate until I had to witness ortho trauma handled in my subsequent ED's). With no doubt in my mind if any of those doctors were asked their opinion of nurses their deep respect and trust would shine through in any answer they gave. And the patients knew it too. Time and time again I had patients tell me--everyone here is just so nice and all of you seem to get along so well!

Fast forward to my last 4 months of nursing before moving to Ireland to become a medical student. I was working as a travel nurse in 2 different emergency departments--one was very rural and one was about 1 hour away from a tertiary center. Something changed, in a very palpable way, when my physician colleagues discovered I was going to medical school. Even though my knowledge base, education and experience hadn't changed--the way I was treated by the docs changed. One day a doc I barely knew and had hardly worked with turned around at the desk and said, "hey! aren't you the nurse that is going to medical school?" Um yes, and apparently word travels fast. He didn't know my name but he knew that fact about me.

Suddenly I was given more opportunities to suture (most of them knew that I sutured up North), I was invited to look at x-rays and shown what they were looking at, I was handed lab work and asked what the differentials were, I was doing small procedures under their direct observation. When I asked questions they really took the time to explain it to me, and then would often grill me about the answer at a later date. I was loving it. But it also left me feeling a little uncomfortable. I hadn't done anything special to deserve this treatment. There were many of my nurse colleagues that would have appreciated (and certainly deserved more than me) the interactions and opportunities I was getting.

If I had consistently had that degree of respect, that chance to discuss cases, and my opinion listened to I might not have gone into medical school. But every time I saw some medical student working through a list of differentials with a doctor or looking at an x-ray I thought "Hang on. I have a brain. I am curious. I want to know the rationale for these choices--not because I am being a bitchy-know-it-all-emerge-nurse-who-questions-your-every-move, but because I want to learn too".  But I was a nurse. And even though as a triage nurse I had to come up with differentials and acuity for every patient I saw I never had the reason or forum to bounce ideas off my physician colleagues. I did learn a great deal from the many fantastic, brilliant, hilarious nurses I've worked with along the way who've taken me under their scrub sleeve and shown me the way when I was walking around in circles (you know who you are...)

But it was that change in responsibility when I was seen as the 'nurse who is going to medical school' -and those extra opportunities started occurring--which solidified my decision. I was making the right choice to become a doctor. I couldn't live in the arctic permanently just so that I could have that autonomy and respect. At some point I'd have to live in the south where I was required to get an order to give a tylenol to a patient. It was too schizophrenic and too bizarre.

So now I am in medical school. And I feel a little schizophrenic again. Because I am still a nurse yet I am also a medical student.  Someday I will be a nurse and a doctor and I don't know what that is going to feel like or what that it going to look like in my practice. 

My first interface with the medical world as a medical student was very brief but gave me a glimpse of what is to come. We have this aspect of our education called the Early Patient Contact program which pairs us up with another medical student and we are given a chronically ill patient and a prenatal patient to follow for 2 years.

Our first meeting with the prenatal was at the doctors clinic, but we arrived before the doctor and the patient. The nurse greeted us and got us all set up in her office, let us use her computer to look at the charts, and went back to the main reception. During our entire interaction I wanted to tell her "hey! I am a nurse too!" but there was no need to and it would have seemed strange and artificial for me to just blurt it out. I guess a part of me wanted her to know that I knew where she was coming from, I wasn't some completely clueless 1st year medical student.

I have to chuckle at the irony of always wanting to come across to the medical students as a 'with-it' nurse yet now I wanted to come across to the nursing staff as a 'with-it' medical student.

I am pleased to see in my lectures from visiting consultants or during PBL sessions, nurses are mostly referenced with respect or used in anecdotes as the person who 'really knew what was going on'. Lecturers have made points to our class like "listen to the nurses", "respect the nurses and their knowledge", "nurses will save your ass" and "nurses will make your life hell if you come off as an arrogant medical student/doctor". All of which I, of course, agree with.

I almost never feel like a medical student, but some days I feel like a mole--sent by my nursing sisters and brothers to see what happens on the *inside* of medical school. What doctors really think about nurses, how nurses are portrayed in medical education. And of course I know, it comes down to the individual doctor and the individual nurse.

I am interested at the layers this metamorphosis will have for me. I like that the lines between nurse and doctor for me will forever be blurred because I know that I will always be a bit of both.   

In the meantime I'll be reporting back and keeping my fellow med students in line.

Wednesday, January 6, 2010

Desperately Seeking New Music

I need a serious injection of new music for my running mix.

Happily my knee has been feeling 100% (ok, maybe more like 97%) for the past 2 months, which means that I've been very slooooowwwlly and carefully getting back into my running regime.


That only took a year of sports med docs, physios, orthos and massage therapists all giving me different advice (and telling me different diagnoses).

So the running is good but my music is stale and since it is January it means I will have more time to ponder the universe on the track while the 'resolutionists' take up the weight room. Like today at the gym I waited half an hour for the gang of 17 year old males (seriously people, who weight trains in a group larger than 2??) to free up a bench. Argh.

Anyway, this is the current mix in case any of you are in the same boat, any suggestions greatly appreciated! (No laughing at some of the songs).

Hotel Yorba--White Stripes
The Waker--Widespread Panic
Fidelity--Regina Spektor
I Gotta Feeling--Black Eyed Peas*
Stayin' Alive--N-Trance
Praise You--Fatboy Slim
Single Ladies--Beyoncé
Rich Girl--Gwen Stefani
Couch Surfer--Bran Van 3000
Black Sheep Mix--Z-Trip and Radar
A Punk--Vampire Weekend
Freedom '90--George Michael
Nothin' Better to Do--The Chordials
Time Bomb--Rancid
Know Your Enemy--Green Day
Pump It--Black Eyed Peas
Maneater--Nelly Furtado
Bug Powder Dust--Bomb the Bass
Where is the Love--Black Eyed Peas

Thanks to Ann Marie for the hand-me-down ipod and Cathy Lee for a great compilation that contributed to the set.

*If you need an intervals song--this is the best one evah.

Something A Little Lighter

As I mentioned, I'll be carrying over a few posts from my former blog...and I came across this one from last January. The time of year is right and I didn't want to do another downer post...just yet. Got plenty of those in the cabinet.


Normally I try and avoid yahoo "news" stories but I stumbled upon this random article today. I usually abhor the onslaught of  "Best Of"*, "End of the Year" lists and "Top Ten" type articles that surface in January...but I will admit...there were some real gems in this piece. It cracked everyone in my house up, so I figured it was 'blogworthy' (my own word for 2008).

My favorites on the list for "Word of the Year 2008" according to Macquarie Dictionary include:

(say 'brohmans) noun Colloquial a non-sexual but intense friendship between two males. [bro + (ro)mance1]

fanta pants**
(say 'fantuh pants) noun Originally British Colloquial a person whose hair is naturally red. [from the orange-coloured soft drink Fanta + pants, with reference to pubic hair as the indicator of hair colour]

(say 'flashpakuh) noun Colloquial a backpacker who travels in relative luxury. [flash(y) + (back)packer] --flashpacking, noun

fur child
say 'fer chuyld) noun Colloquial a pet animal, as a cat or dog, treated as one would a child.

Oh and John, you are not allowed to make any comments which may draw parallels to my travel style and any of the above definitions. :)

*Exceptions being the 'Old Favorites' on IDDX, as well as Maha and OMDG's 10 year review.
**Incidentally, here in Ireland they call red-heads "Gingers" or "Ginger-balls". It is not exactly a term of endearment either.

Tuesday, January 5, 2010

I Wonder If I am Cut Out For This

I was putting off writing about him as every time he crossed my mind, my eyes would involuntarily well up and that lump in my throat would appear.

Now as I sit to write the kilometers are stretching out between us and it has been days since I held his tiny hand in mine. Or rather that he spun his misshapen fingers around mine, holding my index in his soft grasp. I could feel the tiny nodules that marred every joint on his underdeveloped body. I was afraid of putting too much pressure anywhere that would invoke pain. I handled his body like he were made of blown glass. Unlike his mother who dragged him in to my office, her arms encircled under his armpits, the rest of his body hanging awkwardly as she walked forward. Her body banged into him with every step.

He wasn't diagnosed with the congenital disease known as Farber's Syndrome until he was three years old, which was long past his life expectancy. Born to a mother who was 14 and looked like an emaciated 12 year old. It felt perverse imagining Paulassie's conception. Her expression shifted from vacant stare to passively disinterested. She was there, but not really. I wondered about fetal alcohol effects when I spoke to her. So instead I addressed Paulassie's grandmother, who seemed to be not only the primary care giver, but also the only wage earner in a house that supported six people.

His disease was essentially autoimmune, like asthma or arthritis. So few cases documented even the massive search engines online turned up only vague references to the disorder or obscure articles in foreign medical journals. Their bodies bent on destroying their own tissues so efficiently that the children rarely lived past 6 months. Their swallowing mechanisms were faulty resulting in many pneumonia's due to aspiration, their eyes were affected by severe astigmatism which made vision nearly impossible, and their joints would be covered in painful nodules which deformed them beyond function. Their larynx also suffered degeneration which caused these babies to have a distinctive hoarseness. The part that I wished I didn't know, was that when these children died and their brains were autopsied it showed that most had entirely normal brains. Thus many live with cognitive functioning that remains untouched. They are tiny creatures trapped inside a ramshackle body, minds intact.

And so there he was in my office that day. His eyes moving back and forth so quickly that it was obvious that he could not be focusing on anything, any attempt to do so was futile. He had a cough that shook his entire body but he lacked the ability to expel the phlegm which rattled his chest with each breath. He seemed listless but alert. A vulnerable little being on the stretcher. I examined him and shuddered at the sound produced by his lungs, causing me to reflexively clear my own throat.

At first it seemed to me to be a routine examination of a handicapped child who had a nasty lower respiratory tract infection. I spoke with his Grandmother about the importance of thickened fluids, his antibiotic regimen, antipyretics, etc. It was the end of the day and I was anxious to take my long overdue lunch break. What more could I do? I didn't know anything about this disorder except what was outlined in his care plan. I was hoping this visit was almost over. His Grandmother remained still. It became evident that she was not ready to leave.

Then she mentioned their last trip to the Sick Kids hospital to see a specialist, it became clear to me that there was a bigger question in front of us.

At age 4, Paulassie had long outlived other children suffering the same disease. At some point there would be a mark of deterioration, a place where the medical care would shift from multi faceted to palliative. But we didn't know when the point was going to be.
He had been ill for several weeks now, the last course of antibiotics seemed to only marginally improve his health. Yes, it could be viral, but it could be worse than that.

As his Grandmother spoke of their trip South, she told me she would never return Paulassie to a specialist again. "He never treated us like we were people, he never shut the door to his office when he looked at Paulassie, he started doing something on his computer and ignored us." By the end of her remarks she was crying. She was a proud Inuit woman, one of the leaders in this community. A respected Elder. She supported her children, husband, and handicapped grandson. I couldn't help but wonder what the eyes of the specialist saw when he looked at her, or her grandson. Perhaps he thought she didn't understand the situation, that she was simple. How could he explain to her the complicated nature of Paulassie's disease, the likely outcomes? So why bother? Her English wasn't impeccable but I was sure his Inuktitut would have been pathetic.

Maybe it was he that didn't understand. That when you raise a child that is in pain, deformed, and requiring care 24h a day you understand the situation on levels than can never be expressed in any language. Dissected by any specialty. You understand that your own heart aches with such heaviness you dare not even hint at it's weight, for if you did you would surely buckle under the burden.

And so it was there in my gray office, as the snow swirled outside and the wind howled, she asked me without saying a word--was this the beginning of the end? And without making a sound I replied--I don't know.

Paulassie smiled and stroked my finger with his own. He twisted his face toward the voice of his Grandmother while we spoke. I looked down at this sweet natured little being who knew not what was spoken, and what was being left unsaid.

Now the tears simply rolled down her face as she tried to convey her fears and her love for Paulassie. Struggling for words she dropped her hands in defeat,

"he is my heart".

Perhaps all that I learned that day has yet to be revealed to me. What I carry now is an attempt at understanding where people are 'coming from' when we see them out of context in Big Hospitals. Here to see The Specialist. For some it is a journey of 1000km, a language barrier, and a claustrophobic city full of strangers. Unfortunately we can never know where people are truly 'coming from'. Yet I think it is something to consider. Sometimes we can't know that when skimming over a respiratory illness in a small child, we may be holding someone's heart so delicately in our hands.


Since I have made my initial blog private I will be bringing over some of the medical posts from there . Sorry for the redundancy to those of you who've been reading since way back when I was an Arctic traveler. If you'd like to have access to ohtanninbound just drop me an email (address on my profile page). Cheers and Happy New Year!

Saturday, January 2, 2010


This New Years day also brought with it a new niece and nephew for ABB! Indeed. On a blue moon, a full moon, and January 1st to boot.

For the medical peeps: my sister in law is a 40 y.o G2P3, had uncomplicated SVD at 38 wks, male child 6lbs 5oz and female child 5lbs 11oz.

For all the rest: Maxiums Alexander and Ella Jane and my S.I.L Karla are all happy and healthy.

This makes 7 nieces and nephews in total for me now, and certainly the last for all my sibs.

I am so pleased that everything went well...when you are a medical person you can't help but have every complication swirling in your head the entire time someone in your family is pregnant.

I had a moment of pout face yesterday at the thought that I missed their arrival on the planet (and that I wasn't there to give the nurses and docs a hard time hand). One of the frustrating things about living in lands far away from home. Sigh.

No pics of the babes other news (i.e my boring life) I bought a mohair/wool blanket today to get me through the cold damp winter months which remain here on the Emerald Isle. She's a real beaut.

Is it a bad sign when you get that excited about a wool/mohair blend??

Friday, January 1, 2010

New Years, Now and Then

tMy Manfriend's parents are here for the holidays, and we've been doing the tourist-thang with them in Dublin and now back in our neck of the woods. Yesterday we walked around some castle ruins and a small hobby farm. There was a damp chill in the air and the low branches on the trees made the afternoon feel like a scene from Sleepy Hollow. I like this photo because you can see the duck just starting to take flight.

Whether I like it or not, January 1st brings with it the mark in time, the reflection on the year and years passed. Where was I last year? What was I doing for New Years Eve? Well this year I was in my living room eating filet mignon. Tobie and I capped the evening with some very bizarre UK television specials, including performances by Boy George and George Michael (maybe it was part of their community service obligations...)

A street in Dublin on St. Stevens Day
In 2007 I brought in the New Year with John in Morocco. I cannot pretend that I loved every minute of that trip as there were many bumps along the way---lost luggage for 6 days, colder than expected temperatures for climbing, sketchy rooms in Casablanca, roach infested train rides...but John put up with me nonetheless and we had some great times despite the surprises. I thought the contrast in color, cities, food, climate and company from 2 years ago until now was worth posting.

The only day the sooks are closed up and silent. The Feast of Abraham which also happened to fall on New Years Day.
The locals simply referred to it as "le fête" while simultaneously dragging their index finger across the throat. This was usually done with a large grin on the face (making the throat cutting mime that much more disconcerting). They'd excitedly ask us, "What are you doing for the fete???" *slash, slash, slash*.

The fête is a great celebration which often involves the slaughtering a sheep (or goat, etc.) to commemorate the willingness of Abraham to kill his son as it was God's will. Instead--by God's command--he killed a ram. We didn't follow the 'when in Rome' rule on that one but we did enjoy the fireworks and festivities.

A street in Morocco on St. Stevens day.