Fireworks. There have been significant innovations in the field of fireworks! Prior to earlier this week, I last watched fireworks about six years ago through the murky fog enveloping San Francisco Bay. I didn’t witness any explosions of color during that occasion; I merely observed a muted haze of color through the thick air heavy with moisture.

The fireworks over Lake Union in Seattle, though, were remarkable! Instead of the usual spherical explosions of sparks, some of the fireworks exploded into smiley faces, cubes, hearts, Saturn-esque shapes, and floating rockets.

It was truly spectacular!

Video games. My friend, who lives practically on Lake Union, invited me to join him for oven-cooked BBQ ribs (a worthy deviation from my usual vegetarian diet) prior to the display of fireworks. We first met in college and, in addition to becoming my friend, he quickly became my technology consultant (the primary reason why I own a Mac now is because of him). I spied his rack of X-box games and asked if we could play video games after dinner.

We ended up using his GameCube for about two hours, where I tried my hand at Mario Kart (I didn’t finish last every time—that counts as success!) and Mario Party (I never directly captured a star, but I ended up acquiring two or three at the conclusion of the game). The last time I played video games was on a Nintendo 16 machine, so you could imagine my frank shock upon interacting with the console. There are so many more buttons now. And when the controller vibrates, it’s kinda scary. The graphics are unbelievable and the complexity of the games are astounding!

I was also highly impressed with the “mini-games” of Mario Party. Who comes up with these ideas? Who can mow the most grass? Who can clean the windows the fastest? Who can hit the “A” button the most in a circumscribed period of time?

And who dreamed up the idea of a sneezing tree? Whose nose you have to tickle with an unusually long feather???

Residency rotations. I generally enjoy all of my clinical rotations (required or otherwise), though, occasionally, a rotation will deeply resonate with me. I am reluctant to express any further excitement about it—after all, the academic year just turned over and my opinion may change as I learn more—but, thus far, I am eagerly looking forward to working with/serving the chronically mentally ill homeless population. The program emphasizes compassion instead of coercion, the latter which occurs more frequently with patients than is appropriate, and the system employs more liberal (and, I think, more humane) practices than I have thus far encountered in my training.

Sometimes we think that no one else shares our perspectives on social issues; it’s a wonderful relief to stumble upon people who are more enthusiastic than you are about service.

Music. I recently purchased Ulrich Schnauss’s Far Away Trains Passing By—what a fantastic album! The last album that brought me this much joy was Imogen Heap’s Speak for Yourself, which I actually purchased after reading Ezra Klein’s positive review. (I also finally bought Lauryn Hill’s Miseducation—I’ve been meaning to buy it for over five years—though her music doesn’t create the dreamy moods of the former two albums.) I’d like to expand my ambient electronica collection (I got an iTunes gift certificate for my birthday…); if you have any recommendations for albums similar in quality and texture to Far Away Trains Passing By, please let me know.

From the archives. I’d like to think my writing has matured over the past five years; I’d now retell the foley story below (well, actually, all of them) differently, where “differently” means “with greater elaboration and better timing”. I send my gratitude and sympathy to everyone who must work tonight in American hospitals at what may be the height of trauma season….)

I was on call for the trauma surgery service….

I got about one hour of sleep. My pager broke its silence around 2:20am, after a case was shipped off in the ER shortly before 1:30am….

I formally scrubbed in on two operations, done by an intern and the third-year resident (who gives off a hard-core surgery aura): an abscess trimming, and wound cleaning. The wound cleaning was interesting, because the patient was a trauma patient who came into the ER around 8:00pm or so, with, literally, his entire skin and fat layer missing around his right knee, and peeling off his right calf. I had to support this “degloved” leg while the team rotated him so his back could be examined.

I turned green, I know it. It’’s disconcerting to be holding a leg that is practically just muscle and bone. While still alive.

I put in stitches (not very well) on the forehead of the above “degloved” patient. The otolaryngologist (ears, nose, throat doctors) did a stunning job of efficiently stitching up his other facial wounds. And tolerated my blundering well. He seemed cool and more laid back than the trauma team. Which makes sense, I guess. (July 4th, 2007, comment: This makes absolutely no sense at all.)

I put in a foley catheter on a male patient around midnight or so. A foley catheter is a long tube that ends in a bag. The tube portion is pushed up the urethra (the place where we all urinate from) until it reaches the bladder. This allows urine collection from the patient.

I had never put one in before. So the whole room was coaching me while I put it in (which requires grasping the penis quite firmly). The entire room was shouting variants of, “Hold the penis up!” “Hold the penis like you mean it!” “Hold the penis higher!” At the time, I just kind of pushed everything else out of my mind and tried to be efficient… but never in my life have I ever had a whole room yelling at me to “hold the penis”.

What else. Saw some patients. The intern taught me how to clean and re-dress an abscess for a patient on the top floor of the hospital. The room window faced a distant fireworks show. It was a surreal experience, because the patient did not tolerate the abscess redressing well: she as whimpering and wincing and yelping in pain. So while explosions of vivid colors marked the dark night sky, my ears only heard a woman screaming in pain.

That was the extent of my 4th of July celebration.

One disturbing case involved a 15-year-old girl who was shot. She was standing outside with a friend near a club, and someone just drove by and shot her. Through the neck. She was crying in pain, whimpering, whimpering, whimpering… and I felt so angry and frustrated: what do 15-year-olds do outside at 3:30am, and who on Earth just randomly shoots people at 3:30am?

The New England Journal of Medicine published a piece this past week entitled “An Elusive Balance — Residents’ Work Hours and the Continuity of Care“. The author discusses the tension between adequate learning for physicians in training and the challenges of abiding by the current 80-hour work week (driven by the hope to reduce medical errors due to fatigue).

The article discusses the multiple “hand-offs” of patients that occur between residents. This “handing off” ritual is also known as “sign out” and is arguably one of the more difficult aspects of training.

By the time I became an intern, the 80-hour work week was in effect and thus, I am not familiar with the era when Giants Roamed the Earth, when Residents Plodded Uphill Both To and From the Hospital During Monstrous Blizzards Wearing Only Thin Scrubs and Worm-Eaten Clogs After Spending 137 Consecutive Hours in the Hospital.

As a member of the Younger Generation, I find the 80-hour work week frustrating because of “side effects” like the ridiculous amount of signing out we do. (This is not to say that I want to work 80-hour weeks, particularly since so many of those 80 hours are spent fighting bureaucracy rather than in patient care, but that’s another issue….)

One of the greatest aspects of becoming an intern (and thus a “real” doctor) is taking ownership of patients. The responsibility of “knowing” your patient is both humbling and exciting. This is the primary reason why I absolutely do not miss being a medical student. Interns possess the most data: They conduct the interviews, perform the exams, order the tests, share the results, and have the most contact with patient. Though they may not know exactly what to do, they’re often the ones actually doing it. There’s an element of intimacy to this. This intimacy is what we refer to as “caring” for the patient.

In theory, “signing out” provides a thorough yet succinct summary about patients so that while you are out of the hospital, the person who is covering for you has some working knowledge about your patients and can provide care in the interim.

In practice, “signing out” usually consists of handing over several sheets of paper with minimal (but deemed important) information about your patients and reviewing very, very briefly What Needs to Be Done (particularly should Something Bad happen—yes, we try to be clairvoyants).

This is frustrating, particularly when someone is “sick sick”.

Most of us in medicine want to do good by everyone and, in my anecdotal experience, most of us have purposely broken the 30-hour shift and the 80-hour work week rule for the sake of patient care—because of the aforementioned intimacy. Part of it may be the hackneyed “savior” fantasy (and it is absolutely a fantasy!); part of it is honestly efficiency. We want to know the results of the test we ordered; we want to speak with the patient’s outpatient provider to get more information. We also know it is easier to tie up the loose ends ourselves rather than sign them out to someone else who is unfamiliar with the patient.

We also know that the person who is receiving our sign out is also covering upwards of forty patients (because we’ve all done it, too) and thus, we try to “tuck everyone in” (this entry is more about medical slang, apparently) before we go. It’s highly anxiety-provoking to provide care for a Crashing Patient that you don’t know (and when there’s no time to review the chart). We try to limit that experience for our colleagues.

A few people just don’t leave “good” sign out. They omit highly significant details either because they forgot to write them down or they never asked for them.

Then there are the few people that you do not entirely trust and yet, they will be covering your patients. Even though you may leave explicit instructions about Things to Do, you are not totally confident that they will actually Get Done. Or they will do Things You Never Asked to Be Done.

There is something about closely following a patient’s course for a longer period of time. Observing this longer-term progress (or lack thereof) is educational, likely beneficial for the patient, and, because information isn’t changing hands so frequently, potentially creates less errors (there is no data to support or disprove this). However, sleep deprivation is not educational, is not beneficial for the patient, and does promote errors.

And this is also the appeal of outpatient care—there is continuity. The “intimacy” is present and because (ideally) only one physician is managing this one patient’s care, she is (hopefully) less like to commit errors. (Outpatient care, however, does not involve acute medical problems and, often, inpatient work is reduced to the task of keeping someone alive.)

I don’t have any great solutions to this dilemma. Psychiatry is also a field where this issue doesn’t entirely apply: Most patients change (grow, heal, get better, whatever verb you want to use) on an outpatient basis; usually, the goal of inpatient hospitalization is to get patients enrolled (and invested in) outpatient care. It is naive to believe that a patient will be cured of all that ails him after taking a medication for five days while in a hospital.

Shift work doesn’t resolve the “sign out” issue. Having residents to live in the hospital is antiquated and is not a sacrifice anyone—residents and attendings alike—will make. Perhaps residents could have less patients on their panels at any one time, but that would limit the amount of experience residents receive. Would people agree to even more years spent in training? Are there enough doctors in training to pull that off?

In the meantime, we try to teach each other how to provide adequate sign out… and we express our deepest gratitude to our nightfloat and on-call residents who provide excellent care for our patients while we are gone.

It was probably his first time calling a psychiatry consult as an official doctor. The Surgery Intern wasn’t quite sure how to ask the question; he self-consciously fumbled with the words as if they were slippery specimens he had just removed from an abdominal cavity.

It was cute—and, eventually, after rephrasing his question several times, he was able to articulate his question: “We’re wondering if we could get your help with managing this patient’s behavior.”

It’s not the most specific question, but often, it’s sufficient: Something doesn’t seem quite right—can you help us figure out what it is, if anything?

The Surgery Intern had already endeared himself to me with his initial question, but when I called him back with recommendations, I was unprepared to feel so impressed.

“So we’re using This Medication to treat his delirium?” he asked.

“Well, yes, but usually we recommend significantly lower doses for delirium, so that’s why I suggest the taper.”

Tangent: In my experience, the surgeons are actually fantastic at managing delirium, but some tend to be a little overenthusiastic when ordering antipsychotics to manage the agitation associated with it. The general recommendation (on the West Coast; again, this seems to be a coastal thing) is high frequency and low dose; some surgeons end up ordering high frequency and high dose. Consider the example of washing your hands: You wash them (hopefully) at a fairly high frequency—when they are dirty; after you use the bathroom; before you eat—at the small “dose” of a sink for a minute (if that). Now imagine washing your hands during all of those occasions, but in the geyser of an open fire hydrant for fifteen minutes at a time. It’s just too much.

“Oh, I see… so, if I can ask you a question for my own learning—if you’ve got the time—”

I have never heard a surgery intern or resident phrase a question like that!

“—I just read this article about This Medication and increased mortality, but there was also another article by The Big Pharmaceutical Company stating that This Medication doesn’t have an increased incidence of mortality with use. Can you tell me a little bit more about that?”

He didn’t see me smile, but I hope he heard it in my voice.

“So the data about mortality is the most concerning in the elderly…” I began, still in disbelief that a surgeon had asked this question. I should have more faith in my surgical colleagues, yes, but this was clearly an exception—I had met only one other surgery resident in the past who had made a specific inquiry about psychiatric medications. Never mind my fondness for teaching; these questions ultimately help the surgeons take better care of their patients.

“Thank you for your time and help; I really appreciate it,” he concluded.

I was beaming.

I hope internship doesn’t pummel the intellectual curiosity out of him.

What GruntDoc said about “blank” nursing home medication administration records accompanying patients in the ER is true.

It’s terrible for everyone involved.

From the psychiatric standpoint, this further alienates patients with mental health issues (particularly people with psychotic conditions): Other docs may be more likely to assume that the patient’s “altered mental status” is due to any real or imagined psychiatric condition, rather than delirium due to a medical condition. The moment people see antipsychotics or mood stabilizers on the record, some of them may be less likely to pursue as thorough of a medical work-up and, instead, they bark, “Call psych.” Thus, these patients may not receive the prompt medical attention they require. Furthermore, the time we spend in the medical work-up results in time lost for appropriate medical care, as transferring patients from one service (and location) to another often takes much more time than any of us care to admit.

Yes, it’s true: Patients with documented psychiatric diagnoses are often treated differently in the hospital. We feel angry about it, too.

My dad has always loved basketball—these days, more as a spectator, though he played as a point guard for school in his younger days. While I was at UCLA, he followed the Bruins faithfully, often excitedly reporting their progress to me.

The vast majority of our phone calls don’t involve discussions about basketball, but when he gets started, I can hear the enthusiasm growing in his voice. Today, he told me about the NBA draft picks with great interest.

“You know Yi Jianlian?” he started. He didn’t wait for me to answer the question. “He said that he wanted to be in major metropolitan areas with lots of other Asians. That was important to him. I think he said he wanted to be in San Francisco or Los Angeles. You know where he ended up? In Milwaukee.”

“Ouch,” I replied.

“There’s not a lot of Asians in Milwaukee,” my dad continued, “and he doesn’t drink beer.” He started to laugh. “But I think he’s doesn’t have all the right ideas about Milwaukee—it’s fairly liberal out there and they don’t all drink beer.”

He paused.

“But maybe he’s thinking of getting traded to San Francisco or Los Angeles in the future. More Asians in California.”

My dad would be absolutely tickled if either Yi Jianlian or Yao Ming was his son-in-law.

Too bad neither one of them dance! (Never mind the disparities in our ages—especially with Jianlian. Yikes.)