Lessons from Consults: Bad day

When the LEAST obnoxious thing that happens to you is that you accidentally rub sticky skin-prep fluid all over your stethoscope instead of sterilizing alcohol like you INTENDED to….

It’s not your best day ever.

Grab these, not the little swabs that look exactly like these.

Published in: on July 29, 2010 at 11:25 pm  Comments (2)  
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Stories From Med School: Hyperthermia

As a fourth-year medical student, you’re supposed to know enough about what’s going on in a patient’s treatment to be able to follow along with the rest of your team, and even to contribute a few aspects to the patient’s care. As a result, a fourth-year student at my med school is often distinguished from a third-year student by the title of “Sub-Intern”, or “Sub-I”.

I did my Sub-I in internal medicine at the county hospital, and then I requested a rotation in Intensive Care in the same hospital, with one of the toughest old-guard docs the hospital had. I figured I’d learn a lot. And I did.

Anyway, this story is from my ICU month.

—–

One Tuesday at four in the morning, when I was on call with my team, a patient came onto our service in really, really bad shape. He was a young guy (younger than me, which still gives me a touch of existential crisis when it happens), in his teens.

He had been running away from the cops with a stash of cocaine, about eight ounces in a plastic bag. He realized that he was going to get caught, so he decided to get rid of the evidence.

By swallowing it.

And eight ounces of cocaine entered his system. He was unconscious within minutes.

Here’s what cocaine does to you. It cranks up the thermostat in every system in your body. Your heart rate goes through the roof (which is why you can get heart attacks from cocaine use), your blood pressure goes through the roof, your breathing ramps up, et cetera. Your temperature also skyrockets.

When we assessed our friend, his temperature had reached 106 degrees. That’s well into brain-damage territory. If we didn’t bring his temperature down, and fast, he’d die. And if he didn’t die, he’d likely come out of this in a permanent coma.

I’ve never seen my team move so fast.

So, we started an IV of refrigerated saline, and set the drips as fast as they would go. We packed him in ice, and covered him with a cooling blanket that would draw even more heat from him.

If you need to cool someone down, the best places to put the cooling sources are in superficial (close to the skin) areas with high blood flow. In practical terms, that means neck, armpits, and groin.

But that apparently wasn’t even enough. The cocaine was still raging through his system, telling it to RAMP UP! RAMP UP! RAMP UP!

We had to bring his temperature down even faster , and it had to happen SOON! The only other thing we could do was to blow cool air on him in addition to the other measures.

Which meant we needed a floor fan. And as the junior member of the team, it was up to me to obtain one.

In retrospect, the team might have just needed me out of the way; the fan wouldn’t help THAT much. But I didn’t realize it at the time. At the time, it seemed like the most important task in the UNIVERSE!

—–

Let me tell you something about the county hospital. It’s a huge old building with maybe ten floor fans in total. They are all located at the nursing stations.

In August in that part of the country, floor fans become a desperately sought-after commodity, and are fiercely guarded by the nurses. Understandably. That hospital is not the friendliest working environment, temperature-wise, and nurses spend their entire day running around.

But if you need a floor fan in August…especially if you’re a medical student…you need to either run across a really, really understanding nurse…or you need to risk pissing one off.

I did not have time to find a really, really understanding nurse. There was a kid dying in the ICU. And a floor fan would help.

Cue Mission: Impossible music.

I ran through each ward on each floor of the hospital at top speed, taking stairs between floors two at a time. Patients and nurses eyed me curiously as I flew past. A doctor running in a hospital usually means an emergency. But a med student running at four in the morning? Who knew what that meant!

Finally, I located a precious fan on the fourth floor, cooling off the momentarily empty 4 East nursing station.

I then called an elevator.

And made a mad dash.

Three things happened at once.

1) I unplugged the fan and hefted it against my shoulder.
2) The night nurse appeared from a patient’s room.
3) The elevator dinged down the hall.

We both started to run. And we both started to yell.

“Where are you taking that! Come back here! What are you doing?” She didn’t know why I was taking the fan. She just knew that the nursing station would be practically unliveable for the rest of the night without it. Like I said, who can blame her?

“I’m the Sub-I on the ICU team!” Oh, there was no way I was stopping! Patient care trumps nursing comfort, and Sub-I safety! “My pager number is 123-4567! This is for a patient! I’ll bring it back! I promise!”

The elevator doors started to close. The night nurse was right behind me.

I dashed in, just in time for the doors to close behind me and right before the nurse could catch the elevator. I punched the button for the ICU floor so the nurse would not be able to call back the elevator.

I’d made it.

I ran back to the ICU as fast as I could, and we set up the fan. And we worked. And we worked.

—–

The kid was in the ICU until the end of my rotation. On the last day of the rotation, he woke up a bit.

“Hello,” we said.

“Hello,” he carefully said back.

“How are you?”

“Fine.”

Success! We had saved enough of his brain function that he had at least retained enough processing power for a simple conversation! We grinned at each other like idiots.

I left the ICU service the next day, so I have no idea how much function he recovered. But he survived to see his family again. So I call that a win.

And the floor fan was there, helping him stay cool, until I left the service.

—–

On the last day, I took the fan back up to the nurses’ station on 4 East, and plugged it back in.

The nurses all exchanged looks. They knew who I was. And I was all alone, the baby gazelle on the Serengeti of the county hospital wards.

And I slunk out of there as fast as I could.

—–

Bonus round! Which branch of the autonomic nervous system predominated in every single person in that story? Especially the teen?

Ooh!

Just dug something up that I think you guys will like. But I’m already scheduled through the end of the month. So it’ll pop up at some point in the fuzzy future.

I’m just really excited about cleaning it up for you! Stand by!

😀


Visit Natalie Dee’s website.

Published in: on July 23, 2010 at 1:54 am  Comments (1)  

Sympathy. And…parasympathy?

Ever wonder how our body knows how to do things and when to do them? There’s an incredibly complex signaling system in our bodies, working ALL THE TIME, without us having to do anything about it. Isn’t that cool?

Well…

Before you answer, I should inform you. It’s cool. It’s really cool.

If you say so.

I do.

Today I want to talk about the autonomic nervous system. “Autonomic” can be broken down into the roots auto = self, and nomos = arrangement or law. So, it’s the branch of the nervous system that is responsible for self-regulation. And when we’re talking about self-regulation, we’re talking about regulation of all kinds of bodily functions: from how quickly you breathe, to how much you salivate, to how big the pupils of your eyes are.

The autonomic nervous system is divided into two opposing forces: the sympathetic influence, and the parasympathetic influence. Both forces are acting upon every bodily system at all times. It’s like playing tug-of-war between two evenly-matched sides. There’s a balance point between the two opposing forces, and a dynamic system that keeps the balance point in place.

You can see an example of this kind of dynamic equilibrium in the first 25 seconds of this video:

So, what do the sympathetic and parasympathetic systems actually do?

I’ll break it down for you.

The sympathetic system is the “fight or flight” system. I like to remember it as, “everything you want to be doing while you’re running away from a lion.”

(well….hopefully more successfully…..)

So, what would be helpful when you’re running away from a lion?

You want your muscles to work really, really well. So you’re going to make sure they get a really good oxygen supply. You’ll dilate your muscular blood vessels, and your heart will beat faster and stronger to make sure enough oxygen is getting to your muscle cells. You’ll also breathe harder and deeper, making sure you have a lot of oxygen in your blood for maximum delivery.

What else? Well, you’ll want to see really well while you’re running away. So your pupils will dilate to a bigger size to let more light in.

And you’ll also want to inhibit a couple of parasympathetic functions, which… well, you’ll see why in a minute.

The parasympathetic system is responsible for the “rest and digest” functions.

Basically, it’s “everything that your body needs to do…unless you’re running away from a lion!”

The parasympathetic system lowers your heart rate and blood pressure. It slows down your breathing. It constricts your pupils and narrows your blood vessels to direct blood flow from your muscles to other important organ systems. It lets your eyes make tears.

The parasympathetic system increases salivation, which helps in the digestion process. It also increases the movement of the digestive tract, allowing you to digest food and excrete waste.

(Helpful tip: Avoid excreting waste while running away from a lion.)

Usually, these systems find an equilibrium point and stick with it, dynamically pulling against each other to maintain it. And they also react to stimuli, changing the equilibrium point as necessary to adapt to daily needs.

Let’s talk about heart rate as an example. A normal heart will contract about 60-100 times per minute. This represents the physiological balance between the sympathetic and parasympathetic influences. At rest, (such as when you’re sleeping), the influence of the parasympathetic function will increase, and your heart rate will slow. When you’re exercising, the influence of the sympathetic function will increase, and your heart rate will speed up.

Another example: your eyes aren’t completely dilated or completely constricted at any one time; they usually hang out around a particular size (that changes slightly according to age). They use the sympathetic and parasympathetic systems to adapt the diameter of the pupil to the amount of light the eye is receiving.

Then, when the particular condition that’s pulling the system in one direction (say, toward the sympathetic side of things) disappears, the other system (the parasympathetic side, in this case) will exert enough influence to bring the systems back into their favorite physiological set point.

How is that not cool?

Your operational definitions are problematic.

It’s still not cool enough? Fine. I hear sex sells.

Fun with autonomics!

The sympathetic and parasympathetic systems are both involved in sexual activity. The parasympathetic system is responsible for arousal, and the sympathetic system takes care of things such as male ejaculation. The mnemonic to remember which does which? “Point and Shoot”. See, doctors are funny!

“Funny”… “Cool”… “Fun”…. You see, this is what I’m talking about. I’m getting you a dictionary for your birthday.

::Sigh:: Another one?

The other ones clearly haven’t helped.

Okay, fine. It’s not cool and doctors aren’t funny. But I still think it’s pretty awesome. So there.

Oh, Dr. G. We really need to get you a life.

It’s going to have to wait till after residency.

Published in: on July 20, 2010 at 1:48 am  Comments (21)  
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OH. MY. GOODNESS.

Drop everything and go to see Inception NOW!!!!!!

Dear Hollywood:

More movies like this, please! Oh, pretty, pretty please!

Published in: on July 19, 2010 at 1:32 am  Comments (5)  
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Must to share…Take 2!

Because Simon wasn’t even mentioned in the 80s Firefly intro……

People sure know how to make me happy post-call……

Published in: on July 14, 2010 at 12:40 am  Comments (2)  
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Lessons From a Consult Month: Getting it done.

Nothing in the world like working up another team’s patient while standing in a puddle of his urine.

How do I love thee, urban county hospital? Let me count the ways.

1) Urine puddle.

2)

……isn’t that enough for now? Seriously, dude.

Published in: on July 10, 2010 at 11:59 pm  Comments (2)  
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Must to share!

Oh my goodness. I just saw this. I hope it makes you as inexcusably happy as it just made me.

Firefly………80’s style!

Published in: on July 8, 2010 at 11:19 pm  Comments (10)  
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Character Types That Keep Me Hooked: The Unassuming Badass

You know your typical badass? Your John McClanes, your Rolands of Gilead, your anything-ever-played-ever-by-Vin-Diesel-or-Wesley-Snipes…

This is not what I’m talking about.

Those guys walk around with a sneer on their faces, positively EXUDING self-aware bad-assery.

I am badass. Drown in my badassery. I sneer in your general direction.

No.

No, instead I’m talking about those completely unsung badasses. The people who grit their teeth, set their backs to the unmovable mountain, and work quiet, awesome miracles while the overt badass showboats about how badass his bad ass can badass.

These are the people who are just really, REALLY good at their jobs. And they don’t see anything special about that. And they don’t expect anyone else to, either.

In this category, I put the genius scientists, the faithful sidekicks, and the unconventional leaders who inspire through quiet, uncelebrated competence instead of through grand speeches or acts of ostentatious bravery.

Examples:

Martha Jones (Doctor Who)– Eludes an all-powerful world conqueror for a full year, trudging through all countries and climates while dodging capture by evil minions, clearly suffering mightily for the purpose of implementing a plan to free the whole world (including her family, who has fallen into the evil dude’s evil clutches). Kneeling on the floor in front of said conqueror after her capture, begins to laugh even as he commences her execution. Also, a doctor. Which always helps. 😀 (Later turned into a little more of an overt badass.)

Samantha Carter (Stargate SG-1) – Science-fictionally out-MacGyvers MacGyver….while MacGyver is standing there! Genius scientist in practically every field. Just pick a field….knows enough about it to immediately make massive breakthroughs that would take anyone else a lifetime of research, experimentation, and failure. Also passes the Bechdel test, which is incredibly rare in a science fiction show. Badass whether or not she’s carrying a gun.

(I also think Daniel Jackson falls into the “unassuming badass” category, but I figured I’d keep it to one character per universe.)

Artie Nielsen (Warehouse 13) – Regularly works with extremely dangerous objects with a calm-yet-almost-bumbling, all-in-a-day’s-work, long-suffering demeanor. When stabbed by arch-enemy with extremely-dangerous-and-valuable sword, wrestles sword out of enemy’s grip by holding it inside his own body. Bad. Ass.

Penny (Inspector Gadget) – Master of subtlety, used a “computer book” WAY before the advent of ::insert your favorite Apple gadget-of-the-week::, clever enough to both solve any mystery AND make it look like her uncle was the hero. (Which is pretty clever, if you think about it…but also a little diabolical, to make a family member look like the protagonist mastermind and therefore the main target of the bad guy……) But I digress. Regularly takes on criminals so scary, even only seeing their hands can be enough to give an eight-year-old scary dreams. Doesn’t give a flying fart that the show is named after her bumbling uncle. Probably the origin of my love of the Unassuming Badass.

More of these types of characters, please!

Pictures:

http://www.movieforums.com/community/showthread.php?t=17015

http://en.wikipedia.org/wiki/Penny_%28Inspector_Gadget%29

Published in: on July 7, 2010 at 2:38 am  Comments (6)  

Happy Fourth of July!

I’m not working today! So I’m having an all-day picnic with old, neglected friends, followed by fireworks and ice cream!

I hope your day will be as awesome as mine!

Be safe, and have fun!

Published in: on July 4, 2010 at 4:23 pm  Leave a Comment