Home Sweet Home

This week is my last vacation break of my internship year and I've decided to return to and spend some quality time with my folks and my sister. I must say - it's good to be home. Not much has changed since I was last here 9 months ago, and even though there are certain aspects of Socal that appeal to me, I'd still pick SF over LA in a heartbeat.

Busy Day in the RH Clinic

This week I have been working in a county reproductive health clinic in the area (perhaps an euphemism for STD clinic). For me who, like most of the male doctors nowadays, is somewhat deficient in getting trained for gyn exams, it is a pretty wonderful experience. If I haven't learned anything else, I have learned to do pelvic and breast exams efficiently and picked up some techniques to help ease patients' stress.

An interesting observation is that some of the patients have no questions with a male doing their exams, whereas the rest have different degrees of reluntance. A couple of them even freaked out when they saw a guy walking into the room. And while I always keep everything professional, I think it is absolutely against nature when you walk into a room, see this gorgeous 19-year-old blonde, and not have other thoughts. It's kind of a guilty pleasure. It's times like this when I really start to wonder - how much do these patients trust you for them to let you touch their most sacred parts of their body?

A Little Girl Has Made My Day

Today is the last day of my inpatient service rotation. I had a fun time indeed - I've been blessed with a cool, fun team with a GREAT attending that has now become my role model.

As I was taking the escalator down after a long day to get my car, an Asian mother pointed me to her little girl.

Mother: "Ask him if he is a doctor..."
Toddler: "Are you a doctor?"
Me: "Yes, I am." (with a great smile of course)
Me: "Do you want to be a doctor?"
Toddler: "Yes~"
Me: "Good girl!"

It totally made my day.

Pronouncing Death

Every now and then, I'd get a page from the ICU or the floor to pronounce a patient's death. I know people who absolutely hate it; but hey, if you think of it as the rare time when you are 100% certain of your diagnosis, it doesn't really sound like a bad task!

The strange thing about pronouncing death is that it is usually not taught in medical school. It's one of those things that you somehow just know eventually, and everyone comes up with his or her own style after a few runs. As easy as it sounds, to legally pronounce a patient dead requires a systematic approach to avoid the 1 in a million chance that the "dead" patient is still alive and kicking!

When there is no one accompanying the patient, I usually start by greeting the patient by his name. Then I usually examine the patient in this order:
- Watch for spontaneous breathing
- Auscultate for heart beats and lung sounds
- Palpate for carotid and/or radial pulses
- Check pupils and negative "doll's eye sign"
- Apply pressure to sternum for response (I usually skip this if family members are present)

The above should be suffice to pronounce a patient, unless for brain death cases. It may not be comfortable alone with a dead patient, but knowing that the patient's suffering with sickness has ended may come as a relief.

A Tale of Two Young CHFers

Last night on call, we admitted 2 patients with CHF (Congestive Heart Failure) exacerbation. CHFers are nothing new, but what's interesting is that they are both young. They are both obese, and present with shortness of breath as their chief complaint. The similarities end here, however.

CHFer#1 is an obese African male who presented to the ER with SOB for 1 week. He has a long history of atrial fibrillation/flutter that is refractory to chemical cardioversion. He did undergo a successful electrical cardioversion a few years ago. He has a history of medication non-compliance, but apparently has finally been taking his diuretics and rate-control meds regularly. Last echocardiogram shows marked decrease in cardiac function and an enlarged heart. He is a mild-mannered gentleman who has never smoked, only drinks occasionally and denied any drug use.

CHFer #2 is an obese Caucasian diabetic female who presented to the ER with SOB and difficulty sleeping for 1 week. Symptoms started after she ran out of medications last week. She has a history of methamphetamine abuse in which she snorts about $20 worth of the drug every day. She stated her last use was 4 days ago. Her last echocardiogram also shows marked decrease in cardiac function. In the ER, she threatened to leave because no one is taking care of her difficult sleeping, and was uncooperative to the ER staff. At one point, she refuses diuretics, saying that she wouldn't able to sleep if she has to pee every 30 minutes. A Foley catheter would have solved this problem, but she refuses as well.

It is easy to feel pitiful to CHFer #1 because of his pleasant manner and overall tragic history, and as the same time feel angry towards CHFer #2 because of her "obnoxiousness" and her apparent "she has done all this to herself" history. A family physician is all about caring and solving his patients' medical and social issues, but what do you do when your emotions affect your desire to help your patients? What do you do when your patients don't meet your expectation?

You Woke Me Up For THIS?

4:30 in the morning:

Me: This is Dr. L, I was paged.
Nurse: I have your patient here in Room ####; his Accu-chek is 46 so I gave him 1 amp of D50. So I need an order for that.
Me: But you gave the D50 already right?
Nurse: Yeah. I just need an order.
Me: So you ask for an order AFTER you carried it out?
Nurse: I gave him D50 because his sugar is low.
Me: So do you know when you are going to check his sugar again?
Nurse: In about 30-60 minutes.
Me: Okay. Just so you know, you can call me at 6:30am instead of 4:30, and it wouldn't change a thing. Please tell me you are not calling me in the middle of the night just for this...
Nurse: So can I get an order for the D50?
Me: (Arrrrh!) Yes, you may have the order.
Nurse: Thank you. [Hung up]

Just wondering: Can I have an order to not call me for a retrospective D50 order?

Leuprolide for Alzheimer's

One of the clinical trials I was involved in, the ALADDIN study, was terminated abruptly last year because of financial issues from the sponsoring pharmaceutical company. The study had a promising start - Memryte, which is basically an implantable form of leuprolide, has shown to be effective for Alzheimer's treatment in Phase II trials. Some of the patients that I had been following showed improved cognition as well. The theory behind leuprolide, which involves LH production and cell division, is very interesting but is beyond the scope of this entry.

I am glad to see that they are still working on reviving the study. Alzheimer's is a hot research field right now because of its lucrativeness but to the end, the general public will benefit so let's keep them running!

Free Sushi!

A general rule for residents is that they always go where the free food is. The attendance of a noon conference with lunch provided always beats one that says, "bring your own lunch."

So it isn't surprising to see that last night's dinner event at a local Japanese restaurant drew a full house of residents (as well as some attending doctors) from different hospitals. It's free sushi we are talking about here! The talk, which is on hormone replacement therapy (HRT), is sort of interesting. Of course, the fact that the event is sponsored by the makers of Premarin makes some of the recommendations somewhat unconvincing (the take-home message I got seems to be, "when in doubt, give patient the lowest dose" rather than considering not starting the therapy). It is also to my slight surprise that according to the WHI studies HRT actually reduces the risk of cardiovascular events in younger postmenopausal women.

Academic aside, the dinner is fun. The sushis were actually just "alright" at best (and my spoiled palate from the recent Tokyo trip did not help at all!) but the atmosphere is joyful and laid-back.

And did I say it's free? ;-p

Know Your Personality Type

I had a rather interesting seminar this morning on the Myers Briggs Type Indicator - it is apparently the most widely used standardized personality test in the world. It is based on Carl Jung's work on Personality types. There are 16 different types; to find out which type you are, you have to take a questionnaire of ninety-some questions.

I turned out to be a split between ISTJ and INTJ, and upon further analysis I am leaning more toward ISTJ. ISTJ stands for Introvert, Sensing, Thinking, Judgement - people with this type are "conscientious, reliable people who can always be counted on by friends and co-workers." They are "organized and love to set schedules" and "greatly treasure family affairs". They are traditionally-minded and are unwilling to change. They "earn success by concentration and thoroughness". In the medical/health field, careers in general surgery or primary care are a good fits.

So it looks like I picked the right field then :-)

MBTI Questionnaire: http://www.real-properties.com/MBTI/MBTI.asp
MBTI Questionnaire (中文): http://www.ksa.nkfust.edu.tw/guidance/main9b.htm

A Sad Evening in the Hospital

As I was walking out of the hospital after an afternoon of clearing out dictations yesterday, I saw an unusual scene in the lobby - there were a bunch of men in US Forest Service uniforms lining up on one side of the lobby, and not far from them there were about 20 people -some of them were weeping, others were keeping with their heads down. I did not stop to talk to anyone of them as it didn't seem appropriate, but I knew something bad must have happened - our hospital has been taking care of the firefighters who were severely injured while taming the Esperanza wildfire nearby. Later I found out that a firefighter who's been battling his life for 6 days died that late afternoon. That brings the total death toll to five. Even though I don't know the person, I could feel a great sense of sorrow for the lost...