refinementoffire-blog

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I have moved

to here: http://ars-longa-vita-brevis.tumblr.com/

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I have a strong suspicion that the take out served at the ED journal club conference gave me food poisoning. Bacillus cereus perhaps we meet again. 

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I am eating rotten blueberries, preparing for the final night shift. 

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ninjatengu: “Evolution of Doctor Handwriting”

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"Every artist was first an amateur." - Ralph Waldo Emerson

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Math teachers save lives

fabyeroca:

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theconstantbuzz:

Eye Examination

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Dr. Cranquis Answers Ennui

  Dear Dr. Cranquis, I admire you so! I am currently starting my final year of medical school and i just wonder, how do you best manage med training ennui? I have a relatively high baseline level, but sometimes i get these really acute exacerbations. I think the spirit of them is--sometimes med school is a drag, and for my troubles, things just get harder in residency. Thanks to a long circuitous path (undergrad, masters, research leave), the sheer novelty of it all has worn off, and the road ahead seems longer. Currently i am doing my sub-I in a large chaotic urban county hospital and it can be challenging and gratifying, but the patients are so ANGRY, the residents so TIRED, the nurses so OVERWHELMED, the system so IRRATIONAL. Its getting so that even finding surprising things in rectums does not provide the existential marvel that can get you through the day. Maybe because it is because i am a little older and don't fear authority or desire to please quite so eagerly? Deep in my heart, i am committed and so grateful for this opportunity to work with fellow human beings and this chance to acquire these skills. But when the days get dark, how do you get yourself pumped? What is the best Lasix for the soul? voiceofwater

Aw, man, I feel your pain. (And I LOVE your term “Lasix for the Soul” — haha! May I use it as a category title for upcoming motivational posts on my blog?)

I was a very angry 3rd-year med student and intern. I felt surrounded by all those people-types you’ve described, and as powerless as a kitten covered in plastic wrap. My intial (and sub-optimal) defense mechanism was to try tobecome even more angry/irrational than the system, but it didn’t make me feel any better, and it sure didn’t help me become the doctor I had intended to become. And since a big part of my “calling” to Doctorhood was based on a personal and spiritual desire to serve others, I knew that I would have to find another way to cope with the burgeoning stupidity which is inherent in ANY professional education system that has been in existence for hundreds of years.

One “quick” change which helped me cope was to stop thinking about how much road I still had ahead of me, and instead focus on how far I had already come. When I’d be fuming about being stuck with extra OB calls, I’d remember how TERRIFIED I had been of delivering my first baby just a couple years before, and realize how confident I now felt handling the various stages of labor. Perspective-change is not an end-all-stress solution, but it does give you a bit of a boost by highlighting how much closer you are to being a Real Doctor, and how quickly that intervening time has flown by.

It also helps to get away from it all for a short while. I made a big mistake of trying to save up most of my intern-year vacation time until my 9th or 10th month, because of an upcoming family vacation. By the 6th month (around Christmas), I was SO burned out. But just a week away from the hospital, the white coat, the charts and the pager really refreshed my soul and reminded me what Real Life is like. Too often, med students/residents go around with “blinders” on, partly of necessity in order to stay focused, but those blinders can make it feel as if nothing awaits you except 40 more years of dumb people and moronic administrators. Use your vacation time, and use it often.

Your moods will be greatly affected by the people around you, so try to pick good people to surround you. Every med school/residency class has a few sour grapes in it: pessimists and hard-chargers and cutthroats and money-grubbers — don’t spend any more time in their presence than absolutely necessary! When you find a classmate or resident who has a good outlook on medical life and who seems to be handling all the crap with a smile on their face, latch on to ‘em! You can’t pick your attending for a rotation, but you can pick the people that you sit with in the cafe, work out at the gym with, and go to the movies with. (Also: “You can pick your nose, and you can pick your friends, but you can’t pick your friend’s nose.” This is not useful advice for your situation, but there it is.)

One other idea, which I wish I had thought of in med school, but which is really helping to keep my spirits on an even-keel in my practice: find a way of safely venting about all the stupidity around you. For me, it’s this blog, where I can anonymously complain about my intelligent-deficient patients (in a HIPAA-compliant way, of course). In the 9 months or so that I’ve been writing this blog, I really think my attitude at work has improved. Even Mrs. Cranquis notices that I tend to have fewer complaints about work when I get home — now, I’m excited to have had a Close Encounter of the DURRR Kind, because it gives me a new TSK to write! :) For you, it might be an internet blog or forum, a close non-medical friend who likes to hear your Tales of the Dork Side, or a journal that nobody else will ever read, or perhaps a practicing physician who enjoys mentoring students. Get it off your chest, process the poo, and let it go. However, I’d recommend that you NOT choose to vent your ichor on fellow students or residents, especially those in lower classes than you — you’ll just come across as another of those Angry/Crabby residents, and spread the grumpiness around more.

Hope those ideas help, friend. Hang in there!

***Pending Cranquis-Mails: 28***

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AIRWAY 

Red flags of a difficult airway:

(1) Beards - prevent an adequate seal for bag ventilation, can be addressed with application of lubricant or shaving (patient tends to wake up more upset with this). Beards increase likelihood of abnormal anatomy that patient meant for beard to cosmetically obscure, esp micrognathia. 

(2) Morbid Obesity- More redundant tissue, decreased lung volume means shorter duration to desaturation (also in pregnancy), difficulty in positioning (address with shoulder ramp) 

(3) Children 

(4) Abnormal Teeth- large teeth obscure the airway, loose teeth pose aspiration hazard, no teeth prevent seal for mask ventilation. 

(5) Neck - decreased mobility from any type of arthritis, cervical spine injury, meningitis. Penetrating neck trauma and risk of edema, expanding hematoma.  

(6) Anatomy - mouth opening, thyromental distance, or submental distance that are small. Toungues that are big. Mallanpatti scores (assessment of pharyngeal opening and its relative obliteration by base of tounge) that are low. 

yama-bato:Study of a head, Parmigianino (Girolamo Francesco Maria Mazzola)

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Seven more shifts of screaming felons and macerated wound edges. Seven nights breaking into days, of crushing sternums in futile resuscitations, of young man ensanguinating around steel angry bullets, while little old ladies with 7 different essential organs dangling freely before the precipice of death cheerfully demand you hunt down the last vanilla Ensure. Seven eternities of death, madness, exhilaration, futility, triumph, flickering florescent bulbs and coming home with pockets overflowing with stool guaiac cards. 

Andreas Feininger

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The money

there is so little of it.

  I am broke, and often quite stressed by it. 

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Local Anesthesia

The first local anesthetic was cocaine, an alkaloid in the leaves of the Erythroxylon coca shrub from the Andes Mountains. Early Incan society used cocaine for invasive procedures, including cranial trephination. In 1884, Koller used topical cocaine in the eye and was credited with the introduction of local anesthesia into clinical practice [he was introduced to cocaine by one Dr. Sigmund Freud, and became a rich man for it]. In the same year, Zenfel used a topical solution of alcohol and cocaine to anesthetize the eardrum, and Hall introduced the drug into dentistry.

In 1885, Halsted demonstrated that cocaine blocked nerve transmission, laying the foundation for nerve block anesthesia. The search for alternatives to cocaine led to the synthesis of the benzoic acid ester derivatives and the amide anesthetics used today

source: 

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.

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Carbuncles, Furuncles, and Pilonidal Cysts

O My!

"All the hours wound you, the last one kills." Latin proverb

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Work and Home

I have spent the entire weekend with my lover. We are both young and healthy and flush with vigor. But when I am with him between the warmth of his skin and the scent of his hair, i will have flashbacks to the bodies of last night's shift. His warm gaze mingles with the vacant pupils of a cardiac arrest. We are bathed in dim bedroom lights and the haze of wine, but I am glaring at an oozing pus pilonidal cyst under the florecsent glare. If his embracing arms catch the light, i sometimes see only the veins and the needle devouring flesh. I see bright blood, urine and a blunted memory of feces. These things no longer horrify me, but how they irritate me, intrude upon me, like the shadows of equations and undone homework in the college dorms. But why shouldn't the bodies of young lovers so easily meld with the dead, the dying, the fighting?  

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yalovesthecitylights: