4 days

4 days.

In 4 days, we start our long journey to Malaysia. Admittedly, for the first time, I'm nervous- travelling with a 9 month old, on a 20+ hour flight, might just be a challenge.

Before I was a father, I'd always give parents of little babies the evil eye. I'd be thinking, "Your baby had better not be bawling the entire journey", or "What idiot brings a baby on a plane trip?". Not that I'd ever say anything.

Yes, I was a pretty selfish SOB.

But now that I'm a father, I feel a sense of guilt- taking poor Alli on such a long journey, but also guilt towards my co-passengers on Saturday's flight. I'd be hoping that my daughter remains the angel that she is, and keeps the fussing to a minimum.

Yes, in 4 days. This was a relatively last minute trip. We had planned to travel back to Malaysia next year. But, as it turns out, a good friend isn't doing too well with his chemo. We miss them terribly, and hope to bring some cheer to him if nothing else. And we didn't want to wait a year.

And so, in 4 days we start the long journey back to the Land of Satay, Nasi Lemak, Teh Tarik, Char Kuay Teow, and Secret Videos of Politicians Having Sex (if you're Malaysian, you'll understand that last one!).

Of being flatulent

Bad: Farting in front of your patient

Worse: Farting in front of your patient whilst performing a thyroid biopsy

Alas, it happened to me the other day. I almost died; it was one of those "I didn't see it coming" situations. Thankfully the patient and my nurse both pretended they didn't hear it. Or maybe neither weren't sure who did it. But it got me thinking though. What excuse can I give the next time I accidentally let one out in front of a patient?

• It was the nurse (I write her paychecks, so she wouldn't dare challenge me, would she?)
• That's just the sound of the needle aspirator.
• It's normal for your ears to pop or hear things when I stick the 25G needle into your neck. It's just an auditory hallucination.
• That's the sound of the ultrasound's cooling fan.
• Sound? What sound? I didn't hear anything.
• That was just my stomach.
• That's just gas escaping from the thyroid as I prick it.

Then again, if it's a smelly fart, there's probably no way around it. What excuses can you come up with?

A Challenging 'Disease'

Mrs. L kept me busy all week on call. A patient with type 1 diabetes, and like many others, pretty brittle. Has been in the hospital for 7 weeks now, from complications of GI surgery.
Despite stable doses of insulin, her glucose levels would swing wildly, from very, very lows, to very very highs, with no clear change in intake, or insulin.
Over the weekend, she was transferred to the ICU for septicemia. Ultimately her blood cultures grew all kinds of weird bugs. But during the emergent transfer, when the nurses were packing up her stuff, they found a bag stashed in her room.
A bagful of medicines, insulins, syringes, even meth. Many dirty needles. The surgeon then confronted her (and I'm glad this was a no-nonsense, pig-headed, God-complex surgeon) and got it out of her. While the medical and surgical team have been trying to help her, she was doing drugs, and also injecting all kinds of things into her, even deliberately contaminating needles with fecal matter, and pricking herself. She was also alternating injections of insulin and dextrose into her IV port, which probably explains the swings.
Munchausen Syndrome.

Munchausen syndrome is a type of factitious disorder, or mental illness, in which a person repeatedly acts as if he or she has a physical or mental disorder when, in truth, he or she has caused the symptoms. People with factitious disorders act this way because of an inner need to be seen as ill or injured, not to achieve a concrete benefit, such as financial gain. They are even willing to undergo painful or risky tests and operations in order to get the sympathy and special attention given to people who are truly ill. Some will secretively injure themselves to cause signs like blood in the urine or cyanosis of a limb. Munchausen syndrome is a mental illness associated with severe emotional difficulties.

Munchausen syndrome—named for Baron von Munchausen, an 18th century German officer who was known for embellishing the stories of his life and experiences—is the most severe type of factitious disorder. Most symptoms in people with Munchausen syndrome are related to physical illness—symptoms such as chest pain, stomach problems, or fever—rather than those of a mental disorder. Reference: clevelandclinic.org

I've seen perhaps 5 or 6 of these in the last 10 years. Always difficult to prove, unless you catch someone red handed. After all, how can you confront someone and accuse them of lying? Though that gal I saw in residency was making it pretty obvious when her skin abscesses grew enteric bacteria, but these occured ONLY in areas of her body where she could physically reach (frontal body, trunk, none in the back).
Always a challenge to treat- as doctors we are trained to treat the medical problem at hand. With care and concern, medicines, invasive therapy. But that is always with the assumption that the patient's on your side. But how do you treat someone, when that someone is working against you, trying to sabotage things?

Matched!

Not me. My students.

Yesterday was Match Day, the day when all the medical students applying for a US medical residency find out there they go next academic year. A very stressful yet exciting time, one that marks the end of a chapter (of being a student), and the start of a new chapter (well, still a student of sorts, but you have a Dr. in front of your name). The 3 to 8 years of specialty training that follows.

This year, a record 38,000 applicants applied for 26,000 positions of residency. If you're interested, the Match Statistics can be found here. 6% of US medical students were unmatched compared with 50% of International Medical Graduates who did not secure a position. Encouragingly, there were more students matching into primary care medicine this year, a vital area that has frequently been neglected because many (wrongfully methinks) see it as not being glamorous enough.

And so, like someone who has years of wisdom to impart on his 4 students doing their endocrine rotation, what did I leave my students with:

Learn to find your own way. Your career is only in its infancy; at this malleable phase of your life, don't learn to imitate someone for the sake of imitation. Don't do this because that's what Dr. X does. Or use that medication because it was Dr. Y's favorite. Or be conservative or aggressive with your treatment goals, just because.

Rather, read the literature and make your own conclusions about how you wish to treat your patients. Because medicine is as much an art as it is a science. And though I became a 'Doctor' that fateful May 10 years ago (OMFG, has it been that long???), I have yet to master either. Take a step back, and ask yourself, what is the right thing for THIS patient?

And, ah, oh yes, be nice to the nurses. You might have the title, but they have the years of experience. If they tell you they're worried about a patient at 2 am, get your ass out of your callroom to evaluate the patient, otherwise the next overhead page you hear might just be a Code Blue. And, if you piss off the nurses, they can make your life hell.

3 of my 4 students matched (the 4th had to go through the scramble- a very stressful experience- but last I heard he was able to get a spot finally).

Congratulations, guys!

Poll Results

So here are the results.

I must say I'm not too surprised- about half of you preferred to go ahead and see the doctor, eventhough he may be sick and is an infectious risk. If it were me, I'd probably vote the same too.

On the receiving end though, I did feel pretty shitty that day, and was really feeling ill. So, I wouldn't have been able to give good care, not when I was having shaking chills and running a high fever. So, it wouldn't be fair too to expect the sick doc to work; everyone needs their sick days.

But one of you readers did ask though: don't we have colleagues who can cover for us? Alas, only to a certain extent. When patients are already needing to wait 4-6 weeks to see a specialist, it usually means the manpower is lacking enough that there isn't a redundant/extra person just sitting around waiting for someone to fall ill.

So, it's one of those things; in an ideal world, I wish I didn't have a job that doesn't allow for sick days without making me guilty and penalizing my patients.

Thanks for your two cents.

Why is it that everytime I'm oncall, I have this strange urge to poke my eyes out with a pencil?

Anyways, more when I sign off Wednesday.

Right now, our thoughts, prayers go out to the people of Japan, and indeed, the people of the world.

Tremulous times, these are. And with already so many natural disasters, we really don't need any more man-made problems like all the unrest going on in Libya.

Sick Day

And so I'm home sick today. Probably thanks to the munchkin; she has been graciously picking up and sharing whatever bugs there are in Daycare. I've never fallen ill so many times before; just last month I took my very first sick day, in my 3 years of work since I joined my group. And now, just 4 weeks later, I'm down with some crud again.

And truth be told, I felt horribly guilty calling in this morning to tell the office manager to reschedule the patients. For one, I've had a terrible headache since yesterday, I ache, am running a fever of 102.8 F and my throat hurts like the devil. The bed has been very accomodating today, though I feel horrible knowing that some patients waited 6 weeks for an appointment with me, and many probably took a day off planning to drive in to town for the visit. And so, this always gets me thinking:
What would patients prefer? Would someone prefer to just see the physician, knowing that although the illness may be contagious, it's not anthrax? Because, as someone on the receiving end, I'd be pissed if I took the day off to see the dentist, only to have him cancel on me.
Or, would patients prefer to reschedule and not risk seeing a physician who may not be on top of his game because he feels crummy, and risk picking up whatever cooties his nostrils may transmit to his hands, and then to you?
Humor me. This is a legitimate survey and I'd really like to know.

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