Saturday, May 30, 2009


Two explorers are shipwrecked off of a tropical island. They swim ashore to be greeted by a tribe of natives, who promptly tie them up and bring them to their village. Out of a hut walks a man who is obviously the chief. He walks up to the first explorer.

"Death or cheech?," he asks.

The two explorers look at each other quizically. The first explorer, thinking that anything must be better than death, answers "Cheech, I suppose..."

His boundings are cut and he is dragged into the forest. For the rest of the day and night, the second explorer hears his blood-curdling cries which are eventually silenced.

The next morning, the chief comes to the second explorer. "Death or cheech?," he asks.

The second explorer, not wanting to live through whatever the first went through, answers "Death." The chief replies, "Death it is. But first, some cheech!"

The term "cheech" (having nothing whatsoever to do with anything named "chong") is a term that, if not specific to my institution, certainly originated here and virally spread. Much like the structure of the modern residency program. The origins of the term is a mystery, but the legend attributes it to the above story. Cheech is like The Force: it surrounds us, permeates us, and binds us all together.

Cheech is hard to define except by example. A patient with new arthritis may get the classic rheumatology cheech bomb dropped on them: ANA, anti-DNA, ANCA, Ro/La, Smith/Jo, C3, C4, RNP, RF, CCP, RPR, HIV, HepB/C, cryoglobulins, anti-cardiolipins, Russel's Viper Venom test, etc. A new cardiomyopathy has an echo, SPEP, UPEP, ANA, HIV, HepC, TSH, ceruloplasmin, urine copper, ferritin, iron panel, left cardiac catheterization, perhaps a fat pad biopsy, and maybe a right heart catheterization with endomyocardial biopsy. Don't get me started on a new liver, heart, or lung transplant evaluation. May as well open the computer ordering system, start at the top and work your way down.

A story from my intern year epitomizes cheech. A patient presented with a new finger ulcer. Among the workup suggested was cryfibrinogen and cryoglobulin. The lab cannot draw these samples, as it needs to be kept at body temperature from the patient's room on the fourth floor until it gets to the appropriate laboratory incubator in the basement. Cryoglobulins are a pretty standard lab, and I assumed cryofibrinogen was the same. So post-call Ed ordered the tests, and dutifully took a tourniquet, butterfly, and a red top with the necessary accoutrements to the bedside, drew the blood, put it under my armpit, and walked it to the lab incubator. Ahh, the lab tech says, cryofibrinogens go in a green top. Back to the patient's room, tourniquet, butterfly, green top, and accoutrements, apologize, draw the blood, in the armpit, speak to three or four different lab techs in the basement, and find the appropriate incubator (a different one). The lab tech, however, has another problem. No control specimen in the hospital, so they can't run the test. So post-call Ed puts his coat on the back of the chair, rolls up his sleeve, and has a control cryofibrinogen drawn by the tech, who puts Ed's blood in a tube, into the armpit, and back to the same incubator. The patient was cryofibrinogen negative a week later when the test came back.

The first rule of cheech is that not all work is cheech, but all cheech is work. My god, is it work. It's like extra-virgin work.

The second rule of cheech is that scut is not cheech. Cheech may sometimes by scut, but never the other way around. One could draw a Venn diagram:

The third rule of cheech is that it must be indicated and appropriate. It's not hard to find an indication, but it still chaps my hide when a methylmalonic acid and a serum lead level is sent in the first round of a workup for an anemia in isolation. We can't go hog wild because we want to ensure a future of cheech and Mr Obama happens to be relatively nearby.

The fourth rule of cheech is that the more cheech done early, the quicker to discharge. Disposition is first. Cheech flinging is not only encouraged, but expected out of those overnight on-call interns (and unit residents).

The fifth rule of cheech is that in order to be considered cheech, it needs to be gratuitous. It's sometimes hard to make rule three and rule five jibe, but such is the nature of cheech.

And yes, there is no rule six of cheech.

Now you may ask what relation does cheech have to being a good physician? Hard to say, really. Some cheech bombs are detonated reflexively, like a package of unclear provenance at a federal building. And sometimes, those packages are bottles of fine port from the Portugese consulate. But we spend so much time mastering cheech, it's hard not to think that it is one of the primary things I'll be taking from residency. Cheech forces us to think about disease pathophysiology and about disease mimickers right from the time we put in admission orders (rule four). It's not all cheech for cheech's sake.

Tuesday, May 19, 2009

Demented music

I'm done with call! In honor, let's post some music.

I'm always on the lookout for music that is a little, or a lot, insane. Catchy but insane music is among my very favorite genres. Music that could only be conceived by mad genius. Seeds were sewn when blackpetero had me start listening to Frank Zappa sometime around 1990.

In college, the next group to slip right into that spot was Mercury Rev. The song "Something for Joey" is so good, it makes you wonder why every rock song doesn't have trombones, flutes, and noise generators.

Baltimore's own Dan Deacon perhaps exemplifies mad genius for me recently:

BTW, how cool is that Florida NBC morning show to have this dude on? Can you imagine waking up to that? We're talking 16 ska bands! We're talking 19 ska bands! It is one of my biggest failings that despite numerous attempts, I have not seen Dan Deacon before leaving B'more. Perhaps in SF, he does make it out there. I recently got his newest album, Bromst and it is nearly as good as his fabulous last album Spiderman of the Rings. Check out the YouTube for "Crystal Cat."

Tonight, I downloaded the fantastically named Dananananaykroyd. Their song "Black Wax" gives me high hopes. Maybe not as crazy as Mr Deacon, but 1+ more crazy than your average indie band.

Sunday, May 17, 2009

Comfortable shoes. And pens.

I only just barely manage to survive every 30 hr shift. Like a desert nomad or an island castaway, one develops strategies to hang on to life, even if it is just a bare semblance of what your life used to be.

This means routines. How to admit patients. When to sleep, if at all -- do you take your chances before all your patients are tucked in for the night, leaving work for the morning, or do you push it back till 5 AM, when you will most likely be interrupted several times by the lab reporting critical values and the nurses trying to square away everything before shift change at 7? Scrubs when the clock strikes 6PM for the interns. Dinner at the same time every night, if possible (I like to eat late). Sleep vs breakfast vs shower. There's rarely time for all 3, and usually not time for 2.

For me, I have a thing for comfortable shoes. I know exactly which shoes I can make it through call in, and which ones to avoid. I wear Merrells for most calls, because I don't have to lace them if I go to sleep and need to jump out of bed for a code. For the unit, where we have long rounds and we don't walk around the hospital all that much, I wear Naot clogs. Not the most fashion conscious choices, but just a survival strategy.

For me, another big thing is pen selection. We still hand write admission and progress notes, so this is big. Since I am a loser of pens, there's no way that I'm going to use nondisposable pens. Many residents start with the Pilot G2 .07s. I kind of have micrographia so I quickly moved on to the micro point (.05). In my opinion, though, there are a number of problems with this pen. The first, universal to all gel pens, is that they run out quick. They last only a week or two at most. Second, there is a relatively high failure rate for the roller ball -- you'll be using the pen a few days and then it gets either unusuable as it will start to sputter. More importantly, though, is that the G2 is prone to leak. When you are wearing a white coat, leaked black ink in the bottom of the pen pocket is a sign of the G2 user. After my third lab coat done in like this as an intern, I switched to the Uni-ball Signo 207 .05 pens. They do not leak, but there is a relatively high failure rate still of the roller ball. At around $2 a pen, this irks me. Two problems with this pen is that I have yet to find them in bulk at Staples and they cost too much. Like the G2, they are refillable, but I'd rather have a fresh body for the $1 I will save by refills.

Just in time for my Last Call Ever (hopefully), though, I have two new candidates. Today at Target they had the Pilot G2 0.038 Ultra Fine. Enough to make me reconsider the G2. I also picked up the Sharpie Pen fine tip, which I am very excited about.

Wednesday, May 13, 2009

Wow. Just wow

I'm now 7 calls into 4 weeks into q3 call. It's a 6 day call cycle, with a 30 hr shift over the first two days, then the third day is a normal 8-6 ish day and then a 30 hr shift and then a day off. It gets brutal after a while.

The MICU at the hospital is small. So small that the other units make fun of it. It's kind of like the movie "Das Boot":

The "MICU resident 7-0" (a call holding on extension -70) comes on the overhead more than you would like. While it means work, it has also has the highest proportion of hit-to-miss ratio in the hospital. As in, calls worth your time because of sick and/or interesting patients versus just other hospital bullshit. In my 2 weeks, I oscillated two people, both of whom are now extubated, one of whom has left the hospital on room air. That guy had acute rejection after a lung transplant. The other was a 3+ sick lady who we diagnosed with Goodpasture's syndrome. She came in on maximal vent settings after walking into a community hospital 3 days prior with a slight cough. Admitted at 8 PM, we oscillated her, had her on maximal life support, pulsed with steroids overnight. By 1 PM the next day, she had a kidney biopsy, she was diagnosed by 5 PM, had plasmapheresis by 6 PM, and cytoxan a day later. She was extubated after 10 days on the ventilator. It was kick-ass.

Now I'm in the CCU. We have absolutely crazy physiology over there and I'm learning lots. But the call schedule is absolutely brutal. That, and it seems like every call I'm totally thrown for a loop. Last night, I watched a very pleasant woman walk in with a blood pressure of 270/170, then drop her blood pressure to 110/70 with almost no intervention (it had been 2 hours since her last dose of BP meds), become obtunded, started pressors, called the Brain Attack Team (kind of the neuro code team), intubated her, sedated her, CT head, MRI brain and neck. I still have no clue what's going on with her but it is sure intriguing for pheochromocytoma or VIPoma. Or maybe just she just vaso-vagal'ed or something.

Though, it is time for it to be done. Call on Friday, then again on Monday, then I'm done with call. After 90+ calls in my intern year, and probably 50 or so in each my junior and senior years, it seems like the day would never come.