A wall.

My intern was calm, always calm.

The patient's mother on the other hand was unsettlingly still, watching her daughter with distant eyes. Moving her pediatric stethoscope across our patient's heaving chest, my intern closed her eyes in order to focus. Feeling uneasy about what was happening, I stared at my watch and started to count. Twenty shallow yet labored breaths in 15 seconds. Shit.

"She always goes straight to the ICU when I bring her to the hospital," the mother commented. This scene was unfolding about 11 floors too far from the ICU I thought, and tried to mentally urge my intern to pull the alarm. "Come ON Tina! She's in respiratory failure! I do NOT want to do CPR on my last day here..."

We excused ourselves as the respiratory tech came in to administer a scheduled breathing treatment. Outside the room at the nursing station our upper level resident raced over while my intern was on the phone with our attending. She opened the vitals sheet and cursed silently, then dialed in the Rapid Response Team.

If someone's heart stops, a team descends upon the "code" in order to perform CPR. At the children's hospital I was rotation at, a Rapid Response Team could be called whenever a patient is at the brink of disaster. Hopefully the RRT could avert the disaster and prevent patients from coding via timely intervention.

Timely indeed was the intervention. First 3 upper level residents arrived immediately, then a couple of cardiac fellows swung by because we were on the cardiac floor. My intern's calm presence was replaced by a orchestrated chaos, dancing around our patient with the heaving chest.

In the frenetic activity swirling around the patient, the mother was strangely calm, sitting still while observing the action. What kind of emotions were bottled up inside? Was she now simply used to the idea of death's hand constantly on her daughter's shoulder?

My attending was the last to arrive, and avoided everyone in order to walk to then squat next to the mother. He made sure to be at her level, and spoke in a slow and reassuring manner, an anchor while waves rocked the patient's bed. Soon the wires and tubing was disconnected from the walls, and the bed carrying our patient was wheeled out of the room, and to the direct elevators to the ICU. My attending remained by the mother's side, and continued his conversation with her.

When it was time to go, the mother simply squeezed my attending's hand, then shifted her gaze back to the empty space where her daughter's bed had been.

Open your mouth and say ahhhhhh- oh crap!

I can make kids vomit on cue.

That is all.

Intensity

I think I've figured out why my posts dried up this past year. I like to tell stories, of people I've met and of the strange or crazy situations we've been in. For the past year and a half my routine steadily became sleep-shower-study in isolation as I grudgingly converted to the cult of lecture streamers. Why bother spending 5-6 hours at school everyday when I can speed through all of my lectures at 2.5x fast-forward in just three hours in my pj's? Nothing blog-worthy there.

If this is my last post, then you will know it was because I caught some bug from the scores of kids coughing into my face as I try to listen to their breath sounds. I've started my clinical rotations with pediatrics, and I absolutely love it. Today was my first day in the pediatric ER at the local children's hospital. I have been thinking of going into emergency medicine (just skim through some of my previous posts), but now that I am on pediatrics I'm not so sure I could go back into the adult world. Perhaps pediatric emergency medicine?


Lumbar punctures.

The pediatric ER attending delicately unwrapped a sterile tray that held the needle as wide as my clipboard. I looked at the pudgy preteen boy curled up into a soccer ball on the stretcher, then back to the needle. There was no way this was going to end well, I thought.

Instead of finding the landmarks for the needle, the attending started to screw together a strange contraption that resembled a chemistry set. The entire time the attending gave a steady running commentary of everything he was doing to keep the patient relaxed as possible. He promised to notify the patient every time any needles were involved- and to his credit he did so- all except when the humongous one finally went in. Kinda like ripping off the Bandaid at 2 instead of 3 I suppose. Anything to minimize the agony of having the contents of your spinal canal poked around.

Now I am not squeamish but I found myself holding my breath as the needle went in all directions in search of the elusive cerebral spinal fluid. Seconds slipped by and still nothing. What started as a low moan steadily grew as the poor kid's pain tolerance slowly broke down. The attending moved the needle in and out faster and faster as he checked for the clear drop of liquid that would indicate success.

Nothing. For now. Later that afternoon:

"I want you to burn this picture into your head, and never forget it." The strange wailing cry, the mottled purple of the tiny infant, and the sheer rigidness of her back was nothing like what a normal healthy baby should look or sound like. "She's getting the full sepsis work up," another attending explained to the gaggle of medical students in short white coats.

Do you remember the first time you saw an ultra-violent movie in the theaters? For me it was Saving Private Ryan. You aren't the same afterwards. Sure it is fake, but the constant exposure wears you down little by little almost imperceptibly.

I've already seen too much out on my ambulance, so for this little infant girl to give me chills, I knew something was extremely wrong. Microscopic invaders had so thoroughly conquered this tiny body that her organs were starting to give up. Starting to was the key word. If this lumbar puncture could work, our team could speed drugs through her system to combat this deadly intrusion. We were at a critical window however, and this stick needed to work.

A experienced nurse held the tiny baby in a firm motherly grip that forced the tiny torso to lean forward. She put a towel over the infant's head, then put her chin over the baby's head while holding the rest of the extremities with her hands. This must have caused explosions of pain as the diseased spinal cord and brain covering stretched out so that the attending could take a sample of the fluid that bathed the tiny brain. If I had cried as hard as the infant did I would have blown out my eyes.

Seconds turned into minutes as the needle poked around the spine, searching for an entrance into the spinal canal. Suddenly blood appeared and the doctor scrambled to hold a test tube to the open needle as precious drops of clear cerebral spinal fluid reluctantly left the body. I found myself exhaling slowly finally, and my train of thoughts picked up speed again. Okay little kids. Time to show me what you are made of. Cough all you want all over me, but I'm going to figure out how to fix you up right.

So close I can taste the double rainbow.

Hi there.

No, I'm not dead. Just learning stuff.

Lots of stuff. You know, so I can be a doctor.

Sometimes my brain wants to take a vacation, but I won't let it.

Not for another month at least. Then I will be done with basic sciences.

That means I probably know all of medicine, right? Right.

Movie Trailer life

If my life were to be made into a quick montage for a movie trailer, this would be the background music to it:

Mentor tip of the week

Mentor tip of the week: keep your sleep schedule CONSTANT, even on the weekends. If it is off by 1 hour, it's no good. This is from someone who has scheduled residents for 20 years, and would know something about sleep deprivation...



Two big tests coming up soon. Time to know cardiology and heme/onc COLD.

What my roommate left me

I am typing this out in my brand new bed! My roommate moved out today, and left his bed for me. It's one of those fancy Tempurpedic ones. Me likey so far.

But you know what else he left me? A friggin half of a skull. (More specifically, the foramina at the base. The top and the mandible are gone. There. Happy, Ali? haha) I was helping my roommate's girlfriend pack the last of the his stuff while he was busy setting up his new place back on campus. While she was cleaning out the fridge, I flung open his closet hoping to find it empty. It was, mostly. Some books on the floor, but near the ceiling...sat a brownish remnant of a human skull.

Any hope of the skull being fake evaporated when I picked it up; wisps of memories of anatomy lab floated back into view. I remember when our tank received our own human skull to study every nook and cranny. It was a precious gift, but the shuttle driver did not think so later that day. I had to walk home instead of taking the air conditioned shuttle since I was carrying "biological goods without departmental consent." Bureaucratic speak for "get that f'ing skull off of my bus." Of the dozens of skulls dispersing from my medical school that day into the homes of my fellow classmates that day, mine had the pleasure of bobbing up and down to the beat of Daft Punk as I slowly froze on the cold walk back to my apartment.

I put this older, more fractured yet pristine skull gently on my roommate's table. Should I call the police? Or maybe I should first wipe my fingerprints and blame it all on the girlfriend? One thing was for sure though. I poked around EVERYWHERE in the apartment and could not find drugs, cash, or diamonds. Only then did my roommate's girlfriend walk into the closet and see the skull.

Instead of screaming, she just said "oh, so you found it."

Was there something she should have told me a long time ago?

"Yeah...kind of creepy, no? I think it's Cliff's dad's, back when he was in med school. We just kinda put it up there because...well...yeah..."


Faaantastic.


Other news- I helped out with our med school's White Coat Ceremony yesterday. The speeches were inspirational, and luckily the ceremony went pretty smoothly. I think the dean of admissions and the guest speaker have some kind of 30 year grudge/rivalry going on though, because they keep making fun of each other every time they are in front of hundreds of medical students.


On a final note, it was my friend's birthday yesterday as well! She is a recovering Diet Dr. Pepper addict, so naturally I had to make this for her in case of emergency:



I even threw in a set of gloves, but I made sure not to put in a line kit. Didn't want to make it TOO easy...

Lost in translation

1. The patient has no previous history of suicides
2. Patient has left her white blood cells at another hospital.
3. Patient’s medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
5. Patient has chest pain if she lies on her left side for over a year.
6. On the second day the knee was better and on the third day it disappeared.
7. The patient is tearful and crying constantly. She also appears to be depressed.
8. The patient has been depressed since she began seeing me in 1993.
9. Discharge status:- Alive, but without my permission.
10. Healthy appearing decrepit 69-year old male, mentally alert, but forgetful.
11. Patient had waffles for breakfast and anorexia for lunch.
12. She is numb from her toes down.
13. While in ER, she was examined, x-rated and sent home.
14. The skin was moist and dry.
15. Occasional, constant infrequent headaches.
16. Patient was alert and unresponsive.
17. Rectal examination revealed a normal size thyroid.
18. She stated that she had been constipated for most of her life until she got a divorce.
19. I saw your patient today, who is still under our care for physical therapy.
20. Both breasts are equal and reactive to light and accommodation.
21. Examination of genitalia reveals that he is circus sized.
22. The lab test indicated abnormal lover function.
23. Skin: somewhat pale, but present.
24. The pelvic exam will be done later on the floor.
25. Large brown stool ambulating in the hall.
26. Patient has two teenage children, but no other abnormalities
27. When she fainted, her eyes rolled around the room.
28. The patient was in his usual state of good health until his airplane ran out of fuel and crashed.
29. Between you and me, we ought to be able to get this lady pregnant.
30. She slipped on the ice and apparently her legs went in separate directions in early December.
31. Patient was seen in consultation by Dr. Smith, who felt we should sit on the abdomen and I agree.
32. The patient was to have a bowel resection. However, he took a job as a stock broker instead.
33. By the time he was admitted, his rapid heart had stopped, and he was feeling better.

First seen here.

Last week of summer break! Aieee!

Status post deadly race.

I nearly died yesterday. 3 different times. It is surprising how stupid yet lucky I was, looking back with my 20/20 hindsight. I'm writing the following down as a record to learn from, so I never repeat those mistakes, and so that others may benefit as well.

That said, yesterday's events was a wonderful relapse of my adrenaline addiction. After a year of semi-serious running, I entered my first organized race: Los Chupacabras de la Noches 10k. A hard 6.3 miles through wooded trails from 9pm to 11pm. Yes, at night in near perfect moonless darkness. After the sharp crack of the starting gun over a thousand headlamps activated and lit up the trails like drunken fireflies on our sweaty heads. In addition, the trail was marked with flour and glowsticks so that we would not head down the wrong trails and fall to our deaths.

1. The Fall

There were 3 starting waves because for the majority of the race we were literally tearing through the woods in single file lines. If you started in the first wave but run pretty slow you would bog down the hundreds of runners behind you. If you run at a fast pace but start too far down the line you would end up trying to pass runners in front of you. This was my was case, and how I almost died the first time around.

I put myself at the end of the 2nd wave because hell, it is my first race and I did not want to bog down anyone. Or so I thought. For the first half mile it was a press of sweat humanity simply walking up and down trails because of the many bottlenecks as the starting parking lot turned into a road and then into a single trail. Interesting start to my first race, with interesting conversations along the way. Most revolved around my use of Vibram Five Finger running shoes. It was the one thing right thing I did that night because there was no earthly way I could get rocks stuck in my shoe since it was essentially a second skin. I had mastered how to use them after a year of use, and it was freaking amazing. I nimbly dodged grasping branches, dashed up and down gullies, and leaped over rocks with ease.

A little overconfident, I started to pass runners in front of me. I really should have started in the first wave because I stopped counting the runners I passed at 25. My brief hubris blinded me to the first disaster of the night- I nearly fell to my death. I was just passing another runner when several things happened simultaneously: my light briefly went out leaving me in the dark, a root hid the fact that the trail had started to dip, and most importantly the sides of the trail fell away suddenly.

There is no way for me to describe the wave of terror/adrenaline that slammed into me as I realized I was going crack my head open on a rock on the way down. In a split second, I somehow threw a leg out and threw my weight forward while moving down to lower my center of gravity; the rest of that second found me sprawled out on the trail. With the rest of my diminishing wave of adrenaline I peeled myself off the trail before I was trampled to death, or at the very least prevented a domino effect of runners crashing into each other in the dimly lit forest.

For the rest of the race I spent every other second repeating to myself don’t die don’t die don’t die. Lets see. I ran for another hour after that, and there are 3600 seconds in an hour.

I also started to call out roots, rocks, dips, and branches as soon as I encountered them since I was leading my own little pack for most of that hour. We were the 2nd wave people who really should have been in the first wave, just blasting our way through the slower runners in front of us. It is a little weird developing a protective relationship with total strangers that you have just met but never really see. I recognized their voices once they started to pass down my shouts of "rock! Dip ahead!" but that's all I have, because by the fifth mile I was seriously overheated, and told them to pass me up. "Good luck, good luck," I mutter as the alpha wolf loses his pack, quite the emotionally wrenching moment I tell you.


2. The world was ending, according to my brain

I trudged through the last mile in desperation because I really did not train that well for this race. Since I am on summer break, any discipline from the year is long gone, including my usual running regimen. I also conveniently forgot that the water stations were NOT at the end of the race, and thus did not bring my water bottle. This is crucial, because of how the Vibrams work. Normal runners strike the ground with the heel of the foot, which means a lot of the energy is absorbed by bone, ligament, and tendon. When compared to the muscles of your foot, they seem like supermodels on a diet in terms of how much energy they consume. Now with the Vibrams, my entire gait changes, beginning with what part of the foot hits the ground. I run like a cat or a dog, with the balls of my feet touching down on the ground first, with the energy dissipated through the muscles of my foot, and especially my calves (they are humongous now). The upside is I am indestructible- no injuries, no aches or pains anymore. This is how humans evolved to run- and how they caught dinner: endurance running until their prey dropped from exhaustion. But this also means that I need to down swimming pools' worth of water to keep them running each time I run.

By the time I crossed the finish line, the world was ending. I was so dehydrated parts of my brain was shutting down. I wobbled over to the ice chest in search of Gatorade but only found water. Fuck it, I thought and downed cups. Things continued to get worse. I was like a prisoner strapped down for a lethal injection- I knew what was coming and could not stop it. Earlier this year I had taken a sports medicine elective and helped out with the Big City Marathon, and learned about how dehydration and hyponatremia could mess you up.

They were out of Gatorade! Fuck! I thrashed my arms around in the ice chest searching to no avail. I met my immediate need for water, but the disorientation and wobbling got worse. Physiologically, the water was getting into the system, but without electrolytes to keep it in the blood, it floods into the organs, especially the brain. I had just taken neurology so I knew I could not feel my brain swell. But it was because things were horribly wrong. I was going to collapse from lack of motor control, but that I was not worried about. What was scary was the loss of inhibition. For the first time, the primal drive for survival reared its ugly head, in the midst of stormy waves of neurotransmitters and hormones rocking my nervous system. I was exhausted, and human decency did not exist anymore.

I swiftly stole a gallon of water for myself when I knew it I should share it, and that it would only worsen my condition if I drank it all. I almost turned hostile in search of the Gatorade, so I forced myself to dodge the crowd and stumble back to my car. Panicking, I wanted to call my friend in San Antonio to drag me out, but I focused on getting my electrolytes. I slammed back a can of Dr. Pepper and 2 bananas that I scavenged, and then put myself through excruciating stretches to ward off cramps. Like a druggie going through withdrawal, I weathered the physiological storm muttering to myself and walking around in circles.

Looking back it's almost funny how unprepared for this race I was. Should have done a lot of things, planned better. Could have been a lot worse though. There was already one ambulance out for a runner, could have been another one for me if my focus on survival had flinched one bit.

3. Psychopath

Half way home out on the road, I really needed to pee. Thankfully, my fluids and mental status were back to normal, but I was still worried about cramping. Best case scenario my foot cramped and I swerved and crashed. Worse case scenario I swerved and crashed into another car, killing a whole family. However, I never anticipated the situation where I get brutally murdered by a psychopath though.

My bladder instructed that pull over into this decrepit and deserted rest stop. I found my way to the restroom, but what the hell all the men's rooms were locked. In desperation I found my way around to the other side but they were locked as well. Well I could try the women's room.

Before I could try the door, a slowly squeaking wheel announced the arrival of…someone from the far end. From the darkened far end of the stop a strangely muscular man in a janitorial jumpsuit strolled towards me, pushing a mop in a yellow bucket. He was balding, but greasy strings of shoulder length hair waved around in the air. Just like Harold and Kumar.

I took a step towards the door to the outside, just in case.

The guy walks right up to me, stares me down, then points to where he came from. Neither of us say anything but I find the an unlocked urinal and pee in record time. I look around as I head out but there is no sign of the guy. No wet floors or anything. Weird.

The whole way back I'm checking my rear view mirror and keep seeing dirty white vans the entire way home.

_________________________________________________________________

I'm writing this the day after, where I was working as an EMT for the Opera again tonight. I got a chance to do my stuff in the middle of the opera hall, with hundreds of people watching. I even had 2-3 physicians offer to help, but I did not want to get their tux's dirty so I handled it on my own until my backup arrived. And the good karma I earned by saving a lady's life resulted in straight green lights THE ENTIRE WAY HOME. Made a 20 minute trip in 10 without speeding!

You probably do not want to know

From an awesome new find