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.

Swine flu

Man, the guys in infection control at the hospital have been running around with their hair on fire. They now have something that looks like it can justify their existence after weekly bioterrorism/pandemic flu pages since 2001.

H1N1 has a reasonably high case fatality rate, and it is killing young people, which regular old flu A does sometimes. But apparently the vaccine is protective, and oseltamivir/rimantidine does pretty well (which can't be said about this season's regular flu A, which was largely resistant to oseltamivir). The killing young people is what everyone worries about, and I think that's driving the hysteria in large part. But mostly, like so many things, I think everyone has been waiting for a pandemic flu for so long, and so many resources have been marshalled in preparation, that people are unloading.

We got at least 20 emails about it today. In the MICU, we will be the ones seeing respiratory failure, so we got 15 or so pages on the code pager about mask fitting, and how acute respiratory failure will be assumed to be H1N1. Everyone (visitors, patients, staff) will be screened for respiratory symptoms at the door of the hospital. It sounds like any respiratory failure will be placed on full droplet precautions, with use of gowns, gloves, and N95 masks (which cost $5 apiece) for any contact. All this is planned without any cases in the area, but up the coast a bit. We shall what spreads down from New Jersey. If it starts heading south, and there is evidence for person-to-person spread, it will be interesting to watch how people start to flip out.

Torture

So I was sitting in grand rounds last week, it was about conflict resolution, and a near identical talk by a guy who gave a noon seminar last year. Due to the dangers of the iPhone, I was reading some blogs that I frequent, which led me to the Bybee memo. Now I didn't read all 50 pages of it, but some blog posts pointed me to this:

We also understand that a medical expert with SERE experience will be present throughout this phase and that the procedures will be stopped if deemed medically necessary to prevent severe mental or physical harm to Zubaydah.

I thought we had been through this already. Anyhow, just about made me sick to my stomach.

Given that grand rounds was a full hour on conflict resolution, I registered a blog and a Facebook group, Doctors Against Torture. Not that I've done anything about it yet, as that hour of grand rounds was about my only non-busy hour this week. And it's not like I'm so prolific with this blog that I need two. But just saying.

Smallpox

In our senior year, our program director puts together a few after-dinner get togethers with notables from the medical field who happen to live in the area. Lucky for me, this happens at his house, about 2 blocks north of me.

Tonight we had a nice sit down with D. A. Henderson. Interesting guy. He told the whole story tonight of how smallpox was eradicated. Basically, the opportunity to head the WHO smallpox eradication campaign in the 1960s and 1970s was forced into his lap due to a bunch of political machinations. LBJ had a West African smallpox eradication program which he fell into, after working at the CDC's Epidemiology Information Service and rising through its ranks while it was quite small. The Russians wanted the WHO to start a worldwide vaccination program, but weren't willing to back it unless they could pin the blame on America if it failed (as had the previous WHO malarial eradication campaign). So Dr Henderson got basically forced into the position. It sounds like it was a bit of a slog, but in 1980, after a last case in Somalia, smallpox was declared eradicated.

He worked after that on polio, was dean of the JHU School of Public Health, he was high in the ranks in the H.W. Bush administration (besides being a dyed-in-the-wool liberal whose wife headed Planned Parenthood Maryland), and then got sucked back into government after 9/11 to look at bioterrorism.

While it was very fun to speak to him, it was a bit disheartening to hear how many times (as he tells it) he just stumbled, almost by luck, into positions into which he was able to effect massive benefit towards humanity.

Battle stories

Almost diagnosed someone with this today. Last year, one of my buddies did diagnose someone with that, but I could never hope to be that cool.

Sounds like he had food poisoning.

New music

I got the Sin Fang Bous disc today, mostly because of good recommendations on emusic. They recommend it as the "Icelandic Sufjan Stevens." That's pretty apt:



Got the new record by The Pains of Being Pure at Heart, which is great as well. Like a Jesus and Mary Chain type sound but with a late oughties pop sensibility. Also got two by Grizzly Bear, and a really nice double disc compilation from the Red Hot series to benefit HIV. It was put together by some of the members of The National (maybe The Very Guy I Sat Next to at Bertha's Wedding). It is called "Dark was the Night" and it has some fantastic music on it, including a great collaboration between David Byrne and The Dirty Projectors, a new track by The Arcade Fire, and a spectacular cover of Vashti Bunyan's "Train Song" by Ben Gibbard and Feist. Not to mention MMJ, Sharon Jones, the aforemention Sufjan Stevens, etc.

April fools

I don't really enjoy April Fool's Day. Mostly this is because of a pathologic fear of being caught by a joke. I blame it being laughed at in the 4th grade because I thought that the instamatic flu was a real disease (from Shel Silverstein's poem "Sick.") Needless to say, I have diagnosed at least 3 or 4 people with the instamatic flu.

I have, however, grown very fond of the Google April Fool's Day projects. This year's is no exception.