A busy day in the emergency room

I had a great time in the emergency rooms around Vancouver when I went through my third year rotations. I guess I liked the variety of cases that come through the door, and doing what I think is one of the most fun parts of medicine: diagnosing and stabilizing all sorts of patients until the right experts can take over.

But my 4 weeks of emergency in Vancouver was nothing compared to what I did in a rural rotation during my fourth year. In a small town emergency manned by just one doctor, I suddenly became a useful member on the team. The nurses look to me to take on patients so that I can help with the workflow, seek me out to do procedures “because the student should learn this”, and the doctor place me up front and center for my first cardiac arrest code…

During the day, I sutured a few lacerated fingers (I love suturing no matter how many times I do it… I think it has to do with liking to do small arts and crafts that are fun but not overwhelming), examined a few patients with various ailments, pushed the shock button and zapped a patient out of her multifocal atrial tachycardia, all in a day’s work.

But in the evening, things got more interesting. While I was talking to the ER doc about anaphylaxis, a family member suddenly called out: “we need some help!” I jumped up and rushed to the bedside; I interviewed the frail lady just several minutes ago and thought she just had a partial bowel obstruction, and ordered the standard set of workup.

She looked very different now. Her eyes rolled back, and her muscles started to spasm. Her false teeth came loose and was about to fall into the back of the throat when I threw on a pair of gloves and grabbed it.

“Open her airway,” the ER doc said. “Start bagging her. Call a code!” He turned and called out to the nurses.

I grabbed the bag-valve-mask and the thing fell apart. I clumsily put it back together and starting bagging (providing artificial respiration by pressing air into the lungs with the bag) the patient. I was so focused on my task that when I finally looked up, the family member has been gone, a team is already around the patient, and an ECG was showing ventricular tachycardia (and she is pulseless)- one of the most deadly heart rhythms that means certain death if not corrected in minutes.

“All clear!”

The patient jerked while the shock was delivered. I resumed bagging the patient right away, but almost immediately she started showing signs of life, moving her limbs and spitting out her oral airway. I pulled out the airway and the doctor told me to keep bagging her. After a minute or two, she started breathing on her own and I just held the mask delivering 15L/minute of oxygen over her face, and took in the scene.

A nurse was having difficulty with placing the oxygen pulsimeter, another nurse is placing a large-bore IV, and someone else is fitting a bag of fluids into a pressure cuff. The ER doc was giving orders for interventions and investigations. The patient continued to stabilize, and things finally settled. She was saved from death, for now, but we haven’t figured out what she was dying from.

As a part of tests to find out, we ordered an arterial blood gas. This requires puncturing the artery with a needle to draw arterial blood, to find out about the gases and pH values of blood that the body sees. I had practiced on a classmate more than a year ago, so I was poking my head over a nurse’s shoulder to get a look.

She suddenly asked, “where’s the student?”

“I’m right here behind you.” I said.

“You should be doing this.” She said, matter-of-factly.

“I was thinking ‘I wish I could be doing this'”, I said, which was the truth.

So we switched spots. I struggled at first, but another nurse holding the patient’s hand was steady and patient, and the ER doc gave me some directions, and I got a steady stream of arterial blood from the radial artery. First ABG, success.

The ABG later showed that the patient had plenty of oxygen in her blood, and no other abnormalities. “You bagged her well,” the ER doc said. First time bagging a coding patient, success.

Later on that evening, just as everyone felt they’ve put in a good day, a call came in notifying us that there’s a cardiac arrest patient being rushed in by ambulance.

A team of nurses that make up the trauma team got ready in the trauma bay, and I volunteered to do chest compressions. But the ER doc had something else in mind.

“You will intubate the patient.” He said.

“Alright!” I said, excited.

“Have you intubated before?”

“Only in very controlled settings (in the operating room).” I said

“Well, there will be nothing controlled about this,” he said.

We checked the intubation equipment, and someone pulled up the glidescope. The guidescope is basically a camera that shows the patient’s airway on a screen, which often helps visualizing the trachea into which the tube has to be inserted.

After a few minutes of calm when the whole team waited, the ambulance arrived. A nurse closest to the door took a look, and said quietly: “god, he is 400lb.”

The ambulance crew flew in with the morbidly obese patient, and somehow managed to drag him over to our stretcher. The continued to pound away on his chest until our nurses took over. The team got to work, placing IV’s, defibrillator pads, and I pulled over the glidescope.

“Go?” I asked.

“Go.” The ER doc said. “And 1mg of epinephrine!” He said to the medication nurse.

I opened the man’s mouth. His neck is massive, and his tongue seemed as big as my palm. I couldn’t even fit the glidescope into his mouth, and I think it is at least 2 inches too short for him.

“Let’s use the traditional way,” the ER doc said after he couldn’t get a view either.

I pulled up the laryngoscope, and naturally used my right hand to put his head (which must weigh 8kg) into the sniffing position. I saw the epiglottis, and it was impossible to see the vocal cords.

Thankfully I learned how to use a flick motion with the tube in this suboptimal situation, and I got it in one go.

Unfortunately, despite our best efforts, the patient was too far gone. The ambulance crew has been doing CPR for about 30 minutes before arriving to the emergency, and he was in asystole on arrival. The most likely cause of death is a massive MI, and there is little CPR can do in this situation.

The ER doc called it, and commended on everyone’s efforts. He was especially impressed with my intubation.

“Truly a great job. Things were chaotic, the nurses were doing chest compressions, the man is so obese that even anesthetists would have to try hard.” He said. “You won’t have to do a harder intubation in your life.”

Although the outcome of my first case of cardiac arrest was not successful, I left the emergency room at 2am knowing that I have done as well as what anyone in my situation could have, and that was a good feeling for a medical newbie like me.

And I realized: the more I do in the emergency, the more I like it.

 

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Please don’t play mind games with your doctor

I have taken this sad truth as a fact of life: most patients that I interview have an incomplete idea of many crucial aspects of their health. They don’t know what tests have been done, what they are for, what medications they are on, what conditions they have… And the list goes on.

Take for example, several weeks ago I interviewed a relatively well educated and intellectually intact patient, and this is how it roughly went:

Me: sir, what medical conditions do you have?

Patient: nothing, I have been healthy.

Me, knowing any question worth asking once is worth asking twice: any medical problems in the past?

Patient: nope.

Me: ok… What about your heart?

Patient: oh yeah, I had a heart attack and almost died 5 years ago.

So I went through the rest of his body systems one by one to help him remember other things like heart attacks that are generally considered “past medical problems”.

Me: ok, sir, do you take any medications?

Patient: no.

Me: nothing? No medications?

Patient: no.

Me: what about the diabetes and high blood pressure you told me about?

Patient: oh yeah I take metformin, metoprolol, candesartan, aspirin, Lipitor…

Me: orz…

Why did you say “no”? What did you think my question meant before? What if I was less patient or busier, and believed your answers when you so definitely gave them?

I don’t think the patients meant to do this on purpose. Usually it is simply miscommunication or something being lost in the language barrier. And sometimes we are at fault for asking unclear, ambiguous, or misleading questions.

But every so often, I can’t help but imagine a patient must be pulling a prank on me when I take a history. Maybe one day I will ask someone about their surgical history and they will say: “nothing, doc.” “And what’s this beeping in your chest?” “JUST KIDDING! I have a robotic heart! 😀 GOTCHA!!!”

Only in Taiwan

have I seen the following senario so widely accepted to be the norm:

My grandma, who is a happy and pretty healthy 82 year-old, recently had a cough. She has been afebrile, and maintained good hydration and appetite. She has no constitutional symptoms like malaise and weight loss either. Her cough is productive of some yellow phlegm, and it’s been going on for about a week, so she was prescribed some antibiotics and some antitussives, and was asked to follow up in the clinic in 3 days.

Bread and butter primary care, right?

Except she went to a pediatrician‘s office.

And the thing is, I would not have thought twice about this situation a few years ago, because that is really normal in Taiwan where I grew up. There are virtually no family docs (and no patient knows what family docs do even if they see one) on the streets where medical clinics tend to cluster and where patients go see doctors. There is no concept of longitudinal care either; if the doctor in this clinic isn’t helping, patients will go to the next one down the street. (And if all else fails, or if the patients decide the problem is serious enough, they will present to the best tertiary hospital they can get to.)

So that’s what my grandma did after seeing two different pediatricians and still had the cough. She went to an ENT surgeon’s clinic.

Yes. Ear, nose, and throat surgeons who went through years and years of extra surgical training to operate on some of the most vital (airway) and aesthetically important (face) areas of the body are common go-to doctors for mild URTI in Taiwan.

Imagine the hilarity if that happened in Canada. If a 82 year old woman is referred to a pediatrician for a case of mild URTI or bronchitis? Or, heaven forbid, an ENT surgeon? The primary doctor who made the referral would not even be taken seriously enough to be yelled at. The pediatrician’s or ENT’s secretary (or medical office assistant) would probably politely talk to the primary doc’s secretary and ask him or her to check the correct addressee.

Now, this is not a criticism of the patients or the doctors in Taiwan. Both parties are doing what everyone is doing, in a way how everything has been done. In other words, this is the current medical culture of Taiwan, and no one can be faulted for doing things in the most culturally accepted way.

But just because something has always been like that in the past doesn’t mean it should alway be the same in the future. Think about the downside of having streets of medical clinics run by specialists, advertised to be the former attending doctors or even heads of departments of prestigious tertiary hospitals and academic centers, to whom hundreds of ill patients and their worried families present any condition under the sun. The patients have only their understanding of the specialty title to base their self-referral on. “ENT? Sounds like a good doctor for coughing which is kinda in the throat.” “Stomachache? Probably like the ones I had when I was a kid. Let’s see the nice pediatrician who saw little Johnny last week.”

Well, for starters, the specialists would either go mad and burn out (“WHY AM I SEEING 30 CASES OF VIRAL DIARRHEA A DAY AS A COLORECTAL SURGEON!?”) or become content with being a GP. There goes years of intense, valuable specialty training. Also, the patients are probably getting suboptimal care because of their inappropriate self-referral. They can decide that an internist is the best for their child who is vomiting, but the internist may very well not know the complete list of differential diagnoses of pediatric vomiting by heart.

I can probably go on with the problems with the current medical model in Taiwan, but I think you get the idea. The bottom line is, this model probably poses a serious drain on the health care dollar, creates unnecessary confusion and suboptimal care for the patients, and leads to much headaches and burnouts for the doctors.

The big question is, how do we change it?

That, my friend, is a good question. If you can answer it well, you should consider becoming Taiwan’s health minister.

As for me, I just ordered some delish Chinese take out and will be too distracted after the break 🙂

Yum yum yum yum.

Gender equality

is hard to come by. With an emphasis on “equality”, which I would define as being equal, or the same. In the literal sense, of course male and female cannot be the same, nor is it desirable for male and female to be the same. Gynecomastia, virilization, hirsutism, etc. are symptoms for men and women whose hormone balances tip towards the opposite sex.

Ok, enough tongue-in-cheek. No one means “equality” in its literal sense when they discuss the topic of gender equality. So, what do they really mean?

There is no specialty for which the gender ratio is 50:50. There are more male orthopods, and there are more female ob/gyns. There are more female medical students and general practitioners today, which is a shift from the previous era. Is that inequality? Is it unfair that, under the current admission standard, more female medical students are selected over male ones? Should it be tweaked so that we have a 50:50 split every year?

It turns out that equality is a very difficult notion to define. Perhaps it means that men and women are given equal opportunities, responsibilities, reward, and respect. That is all fine in words but complicated in practice, because men and women are biologically and therefore fundamentally different. The average men have higher water and lean mass content than the average women (actually the medical literature defines “typical men” as white males in their 25-35s or something like that but it works for our argument). The average men have higher testosterone than the average woman. This biological difference results in some phenotypical differences that are fundamental to each gender and therefore difficult to change. Such things include: greater physical strength and higher rate of aggression in the average male, and greater social skills and higher rates of depression in the average female. Note that I have deliberately used the “average” male and female because there are of course variability in each population, and we need to focus our discussion on the populations to avoid “but there are some women who are twice as strong as your skinny ass” type of rebuttal. 

But the fundamental difference between the genders end pretty quickly after basic biology and perhaps some psychology. Beyond that, as we move further away from the XX vs XY end of the divide and closer towards the Office vs Kitchen stereotypes, biology plays a smaller and smaller role. If the average women spend more time in the kitchen than the average men, I’d argue that has to do more with society than with biology. And I’d further argue that since society change as people change, there is no reason why the average women have to spend more time in the kitchen than men. Same goes to earning money. Becoming good doctors. And winning presidential elections.

In other words, I think that differences between men and women are due to two factors: biology and society/environment. (Good old multifactorial, nature vs nurture explanation.) Some differences between genders are more due to biology than society, and some the other way around.

So the issue becomes, what kind of societal pressures is in place to keep men and women live life differently? And which of these pressures are desirable and which are not? For one clear case of societal pressure as example: the guy usually buys the diamond ring and proposes to the girl. Is it a desirable societally-pressured inequality? Should we strive for equality and start a movement where girls propose to guys (with awesome computer gadgets, perhaps)? Another societal and historically based inequality: the baby usually takes on the dad’s last name. Does it have to be that way? Should we make the “family name” the mom’s name or the dad’s name based on a coin toss?

Nah probably not. Either proposal would be kinda weird. But any shifting of paradigm in society would be kinda weird at first, so it being weird doesn’t mean we shouldn’t do it. On a societal level, what gender inequalities should be kept and which ones should be fought needs to be dealt with on a case-by-case basis as our culture evolves.

On an individual basis, though, the above argument does not apply. As I mentioned, people are different and probably follow a normal distribution for aggressiveness, emotionality, assertiveness, chivalry, etc. This means there are probably many women more aggressive than many men, many men more emotional than many women, and so on. How a couple could work out the balance will be unique to that couple, and it may very well carry a wide range of normal.

So when someone say: “men should get their balls back and be manly” or “women should be nicer and more girly” in a relationship, I would say: depends on who you are talking about, what their relationship is like, and on what circumstances you are basing your critique. If you are critiquing on the society as a whole, then I would say: good on ya, trying to shape our culture one facebook comment at a time!

Why I am writing again

Blogging has been a pretty big part of my life for a long time, up until some 3-4 years ago. Then for some reason, the blogging me really slowed down. Perhaps it’s because I got into medical school. Not because I become too busy (I did manage to get into Starcraft II and throw tons of hours into the epic interspecies galaxial war), but I think I couldn’t figure out how to fit blogging into my new identity as a doctor-to-be.

You see, I have more than once wrote something that genuinely pissed people off. Not that I was being mean or vulgar; some topics that I was passionate about were just too controversial to not cause a debate. But somehow being a doctor-to-be has caused me to really think twice before posting my opinion on debated topics such as religion, politics, abortion, etc. I guess I felt that since I am training to become a professional, I need to learn to be impartial and unbiased. Or maybe since I will become a searchable figure in a few years after I start practicing, I shouldn’t risk writing things that may alienate significant fraction of my potential patients.

And for the same reason of becoming a searchable name, I expect that it would be very challenging to separate my private life from my public one, so I hesitate to pour my day to day thoughts and feelings onto the pages for the world to see.

But every once and again, I miss the feeling of thinking out loud and hearing my thoughts become sound, watching my voice become words, and knowing my ideas will reach dozens or hundreds of pairs of eyes.

I am getting close to the next phase of my journey: residency. The application process is arguably less daunting than applying to med school, with fewer headaches (no MCAT) and a much better chance for success (overwhelming majority ((like 95% or something))get into a residency program). But more is on the line as well; at this stage of the game, many med students are married or in a serious relationship, and it would be very difficult to go out of province for 2 to 5 years of residency training.

So like how I used this blog to prepare for MCAT and med school interviews, I am going to use it to prepare for residency applications. I’ve been told by many upper year students that one way to prepare is to reflect on my experiences during med school that interviewers are bound to ask. Like dealing with difficult situations, breaking bad news, handling conflicts with colleagues, etc. I was really good at that for my application to med school 3 years ago because I’ve been blogging and reflecting day in day out for years. Now I think it’s time to pick that up again.

So, I will borrow what I said 3 years ago: here comes another page in zeroratio history!

Learned something new about “lightning marriages”

Not knowing much about marriage besides family and friends’ families and Hollywood, I learned something interesting recently. Maybe you will be surprised like I was.

The “lightning marriage” is a term that we use to describe marriages that happen very quickly following a relationship. Prematurely, even. It carries a critical connotation, accusing the couple of not taking the marriage seriously. Imagine a couple dating for a few weeks, and then deciding to get married. Perhaps in Vegas.

The implication is that: only people who don’t care about making a mistake and getting divorced would so carelessly get married. (NB: I’m not suggesting that all divorces are due to careless marriages, or that fast marriages are all mistakes. I’m just saying that if two people get married before they are ready, then they accept the higher risk of regretting this decision later.)

However, recently a friend of mine who has perhaps seen his girlfriend less than 20 times decided to get married next year. Or, more appropriately put, it was decided by both sides of the family that they should get married.

You see, they believe that to date is to love, and to love you must be married.

And since there is practically no chance of them breaking up (by adaptation, communication, patience, endurance, and whatever-else-it-takes, they will stay together), why not get married?

That led me to wonder: “That makes a lot of sense… so, what is everyone else waiting for?” (Besides logistical reasons, of course)

Waiting to find out if it’s the right person to spend your life with?

—> Then it means you think the person you are dating right now might not be the right person to spend your life with.

——> Because if it’s not the right person, after you get married you might still break up. Instead of doing whatever it takes to maintain the marriage.

Huh. Isn’t that interesting.

Who knew lightning marriages could be the most committed, the most gong-ho, the most never-look-back marriages?

I concluded that lightning marriages are like: bam! You and me! Forever! Now!

The only difference is: at least for some people, they really mean it.

Long distance relationship is like driving at night

If a relationship is like driving, then a long-distance one would be like driving at night.

It’s not necessarily lethal, but it is certainly more dangerous than driving in the light.

You can’t see as far in front of you, and many dangers lure out of your sight.

You are more uncertain, and with that comes much unforeseen plight.

With effort and with a strong, steady might, you will most likely survive,

but if at all possible, you should plan to travel at a safer time.

If you must travel at night, keeping the trip short is my advise.

Longer the dark ride, lower your chances dive. 

But in the end, a night traveller must accept the risk, and make it your best drive.

For it is foolish to live in fright when the risk, while increased, is still slight,

especially if you can keep your eye on the destination, and keep your love in the center of your mind.