Farewell to Fairbanks

Folks, it's time to leave the tundra.  Turns out that Captain D is not getting deployed after all, so an extra physician is no longer needed in the clinic.  Here's one last view of the hospital at sunset (3:15 pm!) and the intriguing sculpture in the center of the roundabout:  

The lovely fields of snow behind the hospital seen on a rare sunny afternoon:

My last view of Fairbanks from the airplane:

We flew over the Alaska Range which includes Mt McKinley (known here as Denali, the highest mountain in North America, with an elevation of 20,320 ft) just as the tiniest glimmer of sunrise was beginning:

The silhouette of the snow-capped range became more defined as the sunlight began to manifest itself:

And suddenly, just like that, the Puget Sound was peeking out from beneath the clouds:

Science Experiments in the Sub-Arctic

This thin coating of powdery white stuff on my car window is not snow.  It's precipitate from ice fog:

Today I learned that at 36 degrees below zero, frost can form on your eyelashes if you stay outdoors for more than 5 minutes:

Your own exhaled breath is your worst enemy--the surrounding air is already saturated and unable to absorb the extra moisture, so your breath forms tiny ice crystals as soon as it leaves your airway.  I discovered that if I exhale onto my hair, I can totally frost the tips:

Yes, that spiky white mess is my hair.  With frost on it.  

When the High Temp of the Day is -16 Degrees

We're back to our regular winter programming, with sparkly snow and that familiar sub-zero chill that makes it difficult to be outdoors for more than 15 minutes at a time before your fingers, toes and nose start feeling mildly frostbitten.  I spent  part of the weekend working in the ED, where I ran my own little fast track section for visits that really weren't emergencies at all: sore throat, cough, pinkeye, oral thrush, STD scare.  The ED clinicians use a nifty prescription medication dispensing machine after hours when the outpatient pharmacy is closed.  The genius dispenser looks almost exactly like this candy vending machine:

You order the prescription medication of your choice (nystatin suspension, azithromycin, triamcinolone, etc) on the computer.  A prescription label is printed out, and the nurse puts in a password that allows the machine to release the medication so it can be labeled and given to the patient.  Sometimes the medication gets stuck and you have to bang on the dispenser and yell at it a little, like a real live vending machine.

Knit 1, Purl 2

Friends, a true miracle has occurred:  I have actually taught myself to knit by reading a book.  It is very difficult to learn a complex 3-dimensional procedure by interpreting words & photographs from a 2-dimensional page, but it has somehow happened.   True, I'm still using acrylic practice yarn, my cables get a little jacked up, and every now and then I accidentally add or lose a stitch, but I am now my very own one-woman sweatshop.  Would anyone like to place an order for a hat, scarf, or (if I'm feeling ambitious) mittens?  Specify size, color and yarn type. Anyone...?  Otherwise, it's going to be a very loooong winter (and as Jerry Lewis says, idle feet are the devil's toenails!)

Aftermath

During the day, it continues to rain; then at night the temperature drops and ice starts to form.  There has been so much rain that water is accumulating on some roadways.  Most parking lots are a messy amalgam of slush, ice, and puddles the size of small ponds:

The Fairbanks North Borough superintendent finally decided to close all the schools late yesterday morning, after 5 school buses slid off the road and got stuck in ditches.  Apparently the children of Fairbanks haven't missed a school day since 2003 when there was a massive ice storm.  

The clinic is still open for acute appointments.  Who is risking life & limb to seek medical treatment in such hazardous driving conditions?  A mother bringing her 2-1/2 yr-old daughter in for vaccinations & a well child check that was due at 18 months.  A 19-yr-old woman with an acne break out, 3 weeks away from her wedding.  A 27-year-old woman who wants her IUD removed "because my husband says he can feel the IUD" with his ultra-sensitive penis during intercourse "and the IUD strings are poking inside his pee hole".  Don't get me started on how this is utterly physically impossible because the IUD is in the uterus and the penis can't go through the cervix into the uterus, and how even a board-certified urologist would have trouble getting the soft paragard IUD strings to thread through the penile urethra.

Freezing Rain

Freezing rain doesn't actually fall from the sky in an already-frozen state.  Raindrops are super-cooled while passing through a layer of gelid air just hundreds of feet above the surface, then freeze on impact after falling, forming a thin ice glaze as multiple drops accumulate.  This makes for hazardous driving conditions.  Today's unseasonably warm weather (low 30s) is rare; the last time Fairbanks had rainfall instead of snowfall in November was in 1936!

My car this morning was enveloped entirely in an opaque ice glaze accented with indentations formed by continuous pelting from raindrops.  It looked like an avant garde glass sculpture.  The temperature was hovering at just below freezing as I gingerly pulled the car out of the parking lot and started the treacherous commute to work.  The roads were extremely slippery, as if someone had gone over every inch with a Zamboni.  I'm pretty sure I was driving more slowly than all your grandmothers combined.  The walkway in front of the hospital might as well have been a skating rink; several of us slipped and nearly fell more than once.  I really should have worn ice skates to work.

Museum of the North

When I was a kid, my father enjoyed recounting tales of his own childhood fortitude.  "When I was your age," he would say, leaning back in his chair, "I walked [insert ridiculous # of miles] to school in the wintertime".  Well, Dad, today I walked 4 miles through a pseudo-blizzard for a round trip from my apartment to the University of Alaska, just so I could visit the Museum of the North.

The Fairbanks campus, established in 1917, was the first branch of the University of Alaska.  World-reknowned research is conducted here in the fields of Arctic biology, Arctic engineering, geophysics, supercomputing and aboriginal studies. The Museum of the North is located on the aptly-named Yukon Drive, and the snow was piling up rapidly as I approached the building:

It's a bit of an architectural wonder, with its asymmetrical shaping and specialized climate-control exhibition areas that house 1.4 million artifacts and specimens:

I especially enjoyed the exhibit on Alaskan Native crafts which displayed astoundingly intricate beadwork in the form of collars, bibs, pouches, and slippers:

I would totally wear this Yup'ik dance headdress (made from cloth, felt, seed beads and wolf & wolverine fur) and even these Yup'ik men's dancing gloves (made from leather, sealskin, seal fur and sinew):

 

There was a wonderful display of spirit masks (with part human/part animal faces, worn during ceremonial dances as an appeal to the spirit of prey animals) made from a variety of materials.  The one on the right is an Inupiat (King Island) maskette made from walrus ivory, mammoth ivory, baleen and feathers:

And there were delicate patterned baskets woven from grass, and a wonderful display on the ulu (an Inuit all-purpose knife traditionally used by women) made from steel, copper, brass and bone and used for skinning & cleaning animals, chopping food, cutting children's hair, and trimming blocks of snow and ice for igloo-building:

I could certainly use an ulu right now, to give myself a much- needed haircut...

The Crazies Are Coming Out of the Woodwork

A 55-yr-old woman tells me she was sitting in church on Sunday when she suddenly felt pain and "chills in my vagina".  I'm not sure what she means, and she doesn't know either.  All she knows is that her "pee smells bad".  Ironically, she is wearing a gallon of cologne and the fumes are making me woozy.  I quickly perform a pelvic exam before her cologne knocks me out completely, and there is nothing out of the ordinary.  Her wet mount, KOH prep, urinalysis, and cervical swab for chlamydia & gonorrhea are all stone cold normal.  Maybe having chills in your vagina is not such a terrible thing after all.

A waif-ish 32-yr-old woman comes in and spends 20 minutes complaining about frequent headaches that don't respond to ibuprofen.  She is vague about her symptoms, and all the medications I mention (triptans, beta-blockers, neuroleptics) she thinks she's already tried without relief.  She doesn't have medical records from her former neurologist.  "I had percocet once," she says coyly, "and it was too strong."  She asks for tylenol #3 (with codeine), "just until my medical records arrive."  Against my better judgment, I give her a limited prescription for 10 tablets with no refills.  Two hours later, she returns to clinic pouting, led by her grim-faced husband who is dressed in army fatigues and combat boots.  Turns out she's been in & out of treatment for an addiction to prescription narcotics & benzos for the past 4 years, but none of this is in her medical chart.  Needless to say, she'll be returning to treatment as soon as possible.

Sometimes I get a more satisfying case that makes up for the crazies, like the 10-yr-old girl with recurring muscle spasms in her left trapezius.  She had been seen in February and given a trigger point injection which provided good relief for several months.  She had full range of motion and normal strength in her shoulders & arms, but I was disturbed by a subtle asymmetry: her left shoulder was slightly higher than her right; and her left scapula was just a hair more prominent than the right.  She had been told that this was due to "stress".  I ordered a series of plain films which revealed mild scoliosis manifested by a teeny 11.9 degree levocurvature of her thoracic spine.

I wonder if I'll ever get used to having 20-minute appointment slots. It rarely ever seems like adequate time to spend with each patient, especially when it also encompasses the time it takes for the medical assistant to call the patient from the waiting room, take vital signs, and review allergies and medications.  By the time the patient is ready to be seen,  I'm lucky if there are 7 minutes left in the appointment slot.  It only works if it's a relatively straightforward medical problem, or if the patient can give an awesomely concise synopsis: "I'm a 19-yr-old G0P0 with a history of chlamydia, continuing to have unprotected sex, here for evaluation of crampy low abdominal pain with unusual vaginal discharge, s/p an exploratory laparotomy for what turned out to be severe pelvic inflammatory disease with Fitz-Hugh-Curtis syndrome 3 months ago"...[I really did see that patient!  But without the neat synopsis]

The Acronyms Are Driving Me Crazy

Every day I get memos in my military email account peppered with acronyms I'm not familiar with.  DMHRSi?  NCOIC?  TCON? ERD? I need some sort of acronym secret decoder ring to understand my email memos.  Even the faucet handles at the clinic are etched with acronyms: HW for hot water, CW for cold water:

Sub-Zero

Like clockwork, now that it's mid-November, sub-zero weather has arrived in Fairbanks.  Tonight the temperature dips down to -5, and tomorrow we have -20 degrees to look forward to.
How long does it take hot water splashed onto the windshield to freeze?  Less than two seconds.  Not. Kidding.
Ice fog: Fact or Fiction?  Ice fog develops when warm water vapor (from car exhaust, exhaled breath, etc) meets super-cold air, causing microscopic ice crystals to form in the air.  The frigid air can't absorb these ice crystals which congregate to form a dense cloud.  When it dips down to -30 degrees, I'll be sure to run outside just to exhale and watch my breath form a tiny cloud of ice fog that doesn't dissipate.
Does wet hair freeze when you go outdoors in sub-zero weather? I'm not brave enough to perform this experiment.
How short are the days? Today we had 6 hours 16 minutes of daylight, and each day gets progressively condensed by 7 minutes.  By winter solstice on December 21, daylight will only last for 3 hours 42 minutes [Please, sir, may I have more vitamin D?]

The Land of Aurora Borealis

It was an All-Asian night at the Aurora Borealis Lodge: just me, two visitors from Los Angeles, two from San Francisco, and our affable host Mok & his family.  The Lodge is 20 miles north of Fairbanks, on Cleary Summit (elevation 2000 ft), on a hill overlooking a beautiful forest, with a spacious viewing deck facing northward.  When we arrived at 10:30 pm, the sky was already glimmering with faint patches of aurora radiating modestly.  Over the course of the next 3-1/2 hours, we experienced an astounding display of auroral forms.  I've seen photographs of the northern lights, but still images can't convey the amazing dynamic nature of the phenomenon.  The greenish-white light morphed from a swirling plume to a billowing tower to a glowing arc across the sky, then back to faint patches with tiny delicate rays.  The light appeared white when viewed with the naked eye, but it took on a phosphorescent greenish hue when photographed at high shutter speed with a 10-second exposure.  My low-tech camera couldn't capture the images properly; I was envious of the overnight guests from Japan who had scurried out from their accommodations armed with tripods and SLR cameras with wide-angle lenses.  Here's a series of aurora borealis video clips that I cribbed from the University of Alaska museum:

The aurora borealis is best viewed on clear nights with minimal moonlight when the level of geomagnetic activity is elevated.  Activity is measured by the Kp index which ranges from 0 (no activity) to 9 (extremely high activity).  The greater your latitude, the less geomagnetic activity is required for the aurora to be visible.  The optimal location to view the aurora borealis is within the circumferential band that extends from 60 degrees to 70 degrees magnetic latitude, known as the auroral oval:

When the level of geomagnetic activity increases, the auroral oval starts extending southward, and the northern lights become visible at latitudes below 60 degrees.  There are entire websites dedicated to predicting when auroral activity reaches levels high enough to be seen.   Fairbanks, at the magnetic latitude of 64 degrees, only requires a Kp index of 1 for aurora-watching.  Seattle, at the magnetic latitude of 52.7 degrees, would need a Kp index of 7.  And Mexico City, at the magnetic latitude of 29.1, would need a Kp index of 9+++++++++

Where All the Girls Have PCOS

I haven't been here very long, but I've already seen 9 young women with polycystic ovarian syndrome.  Many have the classic symptoms of irregular menses with anovulatory cycles and hyperandrogenism manifested by acne and male pattern hair distribution on the upper lip/chin & linea alba/periumbilical region; some even have the characteristic ovaries with multiple tiny cysts.  One thing they all have in common is their desire to become pregnant; most of these ladies are between the ages of 19 and 23 and newly married.  Seeing 9 versions of the same problem is like being in some kind of bizarre Medical Twilight Zone.  I found myself prescribing clomiphene for the first time in an attempt to induce ovulation in a 22-year-old with normal FSH (follicle-stimulating hormone) levels and no symptoms of premature ovarian failure; she had been using an ovulation kit every month and was able to document that the last time she ovulated was 12 months ago!

The Irrepressible Urge to Buy Stuff

Something about the cold of winter and the desire to nest fosters an irrepressible urge to buy stuff.  My total time here will be less than 10 weeks, but I somehow ended up with a box of 45 tall kitchen trash bags and 6 rolls of paper towels.  I don't know how to knit, but I seem to have procured an entire set of bamboo size 7 knitting needles, circular needles, double-pointed needles AND a 5.5 mm crochet hook.  Witness my newly-purchased arsenal of thermoses:

Why would you need more than one thermos, one might ask.  One I use for coffee or tea; the other is a food thermos which is spectacular for transporting soup to work.  So far I've made a hearty split pea soup and a surprisingly lovely miso soup with tofu & toasted nori.
The thermoses also come in handy for those special moments when you really need hot water: for instance, when winter elements conspire to encase your car trunk hinges in ice so that your trunk is completely frozen shut.  Because if you're trapped in your frozen-shut trunk without 2 thermoses full of hot water, this trunk release cable will not help you:

Acute Appointments Are Never Quite What They Seem

I've been seeing most of the acute same-day appointments at the clinic, and 95% of them are far more complicated than initially advertised.
Runny nose & sore throat turns into a 32-yr-old G4P3 at 25 +3/7 wks with a history of 3 c-sections, recent gastric bypass surgery resulting in vitamin B12 deficiency, preeclampsia in 2 previous pregnancies...and a positive culture for strep throat!  And did I mention allergic to penicillin?
Urinary frequency becomes a 34-yr-old female with uterine fibroids, polycystic ovarian syndrome with associated insulin resistance, hypothyroidism, and a recent history of endometrial ablation for menorrhagia who stopped taking all of her meds (except xanax!) and has been feeling the urge to urinate Q15 mins for the past 5 months
Abdominal pain is actually a 19-yr-old diagnosed with ulcerative colitis at age 14 who is starting to have frequent stools with blood & mucous after a year of remission without meds...and the nearest gastroenterologist is 360 miles away in Anchorage!
Foot pain is revealed to be a 24-yr-old woman with chronic arthralgia, a recent ANA titer of 1:40 in a speckled pattern and a family history of lupus, awaiting a referral to the nearest rheumatologist 2245 miles away in...Seattle! [maybe she'll let me accompany her to her first rheum appointment and I can check on my apartment and say hello to my peeps at Swedish?]

My Military Cheeseburger

I had my first cheeseburger from the hospital cafeteria today:

Not bad for $1.70...but I've been bringing my own lunch to work almost every day.  Most grocery items are readily available in Fairbanks, only slightly more expensive than Seattle with the exception of certain items like almond butter:

With the lack of sunlight in the winter season,  foods tend to be infused with vitamin D to the maximum extent of the law:

           

My cooking is limited mainly by the sad display of abandoned kitchen implements that came with my furnished apartment: plastic spatula, can opener, miniature cutting board, slotted spoon* (*currently being used to clear snow from the car).

I like to travel with a compact Wusthof knife sharpener if I'm going to be away for more than a month.  It seems less risque than attempting to stash a sharp knife in my luggage and getting tagged as a national security threat.  But alas, the knife in my apartment is cheap, unstable, serrated and very very dull.

I can tolerate a lot of things, but shoddy cutlery is not one of them.  I took a field trip to the cavernous Walmart on the other side of town--purportedly the largest Walmart in the entire country, where people come from all over Alaska to stock up on supplies.

I found a 5" Santoku knife and a 3" paring knife, both significantly more stable than the sad serrated knife in my kitchen.  The new knives sharpened up beautifully after a few rounds with the Wusthof. Now I can slice sweet potatoes without fear of dislocating my wrist.

Four Degrees Fahrenheit

The weather has been relatively mild (mostly in the 20s to 30s in daylight, dropping to the teens overnight)...until today when it was still only 4 degrees at high noon.  Yes, now I will admit that it's a teeny bit cold.  I've been told that the snowpack which has developed over the past few weeks will likely persist until May.  Luckily, Fairbanks has a crack snow-plowing team that seems to work round-the-clock.  Because Fairbanks lies at the bottom of the Tenana Valley, cold air tends to accumulate over the city. The average low temperature in the winter is around -25 degrees, but it has gotten as cold as -60 degrees in the past.  Being just 188 miles south of the Arctic Circle probably doesn't help.  What amazes me is that, despite the cold and the snow, many people still travel on bicycles--you can see bicycle treadmarks all over the sidewalks:

THE VIEW FROM MY WINDSHIELD
October 17:

October 23:

October 30:

Cleared and All CAC'd Up

I'm cleared to see patients!  Finally!  I've managed to score the following essential items:

1. Hospital ID badge with a blurry picture of me sitting in front of a huge American flag, clutching a tiny notebook filled with crib notes on how to navigate the clinic EMR system.

2. CAC (Common Access Card): a smart card issued by the Department of Defense with an embedded circuit chip that enables me to access the computer system, sign documents electronically, and send encrypted email...and BONUS: it also doubles as an identification card under the Geneva Conventions [...in case I get captured by the enemy on my way to work??]

Processing for the CAC involves the use of an optical fingerprint scanner on your right index finger.  Turns out that after 7 years of obsessive-compulsive handwashing through medical school and residency, my fingerprints are quite worn out.  The clerk had me try alternate fingers from my right hand: ring finger, pinky...all terrible quality prints.  Then, as a last resort...

Clerk: Can you place your middle finger on the scanner?                                         Me: Please don't tell the Feds I'm giving them the finger

Will my lack of readable fingerprints cement my future as a crime kingpin?  Stay tuned...

Sunrise Over the Hospital

The clinic is situated inside a 32-bed hospital, built in 2007 with a very sleek and modern look.  After entering the foyer through the first set of automatic doors, you are greeted with a delicious blast of heated air just before you step through the second set of automatic doors into the hospital lobby.  The patients are all military personnel and their dependents.

Most of the clinicians are also in the military; they wear army fatigues and combat boots in clinic.  I am extraordinarily jealous of their multifarious pockets.  I've never heard anyone addressed by their first name: it's always Sargeant B or Major V, or, in my case, Doctor or Ma'am.  The office that I share with Major V is haunted by a poltergeist who:
a) keeps the temperature rather chilly in contrast to the rest of the clinic which is reasonably warm
b) mischievously turns off the light without warning several times a day

The Alaska Railroad, which connects Fairbanks to Anchorage, runs part of its Denali Star route behind the hospital:

3 Levels of Classified

Classified information is rated as one of just three levels: Confidential, Secret, and Top Secret. Somehow I always envisioned a more complex hierarchy of progressively classified information: from nylon-static-cling Level 1 Confidential, to ironclad-amber-waves-of-grain Level 5 Confidential, all the way up to hermetically-sealed-and locked-out-of-my-apartment-AND-my-car Level 23 Top Secret.  My military issue laptop is unbelievably secure...so secure that I am not authorized to install my own office printer.

Maybe this explains why I've been here for an entire week and I still haven't been cleared to see patients [perhaps they discovered my overdue library book fine from 1994, or my occasional propensity for jaywalking...?].  I remain officially in Processing Purgatory.

We Use an Irritant Smoke

The Respiratory Fit Test
This is the rite of passage where you try on a special mask that covers your nose & mouth to make sure you have the correct size that will prevent you from inhaling airborne pathogens like tuberculosis or [insert your favorite airborne pathogen].  In all the hospitals where I've done rotations, an aerosolized form of saccharin is used to test the fit of the mask; if you perceive a sweet taste after the saccharin is sprayed, your mask does not fit properly. My fit test this week was conducted by an RN in the Occupational Health building.

Military Occupational Health RN: Most places use saccharin to conduct the fit test, but we use an irritant smoke
Me: What?!

It's true!  She was literally blowing smoke at me after I applied the N-95 respirator mask, and she had me turn my head in various directions, count to 10, and bend forward at the waist, all to prove that the mask fit snugly enough to prevent smoke from entering my airway.  It was after she allowed me to remove the mask that I was fully exposed to the "irritant smoke" and promptly launched into a prolonged coughing fit.  Now I feel like I have emphysema.

Snowfall

My weapon of choice for clearing snow off the car in the morning:

The slotted spoon is surprisingly adept at scooping out snow from odd little crevices in the region of the windshield, and there's something oddly genteel about wielding a spoon in the wee hours of the morning.  [Would you like one lump of sugar or two...?]

When I picked up my rental car at the airport,  the sales clerk handed me a blue extension cord and explained it was for the yellow plug protruding from the grille of the car:

    

The other end of the extension cord plugs into an outdoor outlet that is controlled by a mysterious red switch in my apartment:

   

Everyone's car in Fairbanks has an engine block heater that helps prevent the coolant around the engine from freezing overnight, making it easier to start the car in subzero temperatures.  The block heater has a plug extending out through the grille of the car so that it can be connected to an AC power outlet.  All outdoor parking lots are equipped with rows of power outlets for exactly this purpose, although it is tempting to imagine appropriating the outdoor outlet for a waffle iron or a toaster.

Prepared to Vanquish Fires!

Day 2 in Fairbanks: a very toasty 38 degrees. The apartment complex staff that I met yesterday was rather...eccentric. When I explained that I was scheduled to move in by my locums agency, she looked at me suspiciously and commanded, "Go stand over there", pointing to the farthest corner of the room as if I were a domesticated but still slightly dangerous grizzly bear that needed a time-out. I signed a ton of paperwork as she went over a zillion rules & regulations I was LEGALLY required to follow.

Most exciting part of the day: testing the fire extinguisher in my apartment (one of the LEGAL requirements). I released the fire extinguisher from its wall mount, pulled the pin and sprayed into the kitchen sink, releasing a high pressure gush of yellow powder which immediately coated the entire kitchen. Since I am LEGALLY required to NOT open the windows between the months of October and May (for fear of the entire apartment freezing into a solid cube of ice?), I had to settle for the fan above the stove.

Please Tone Down the Atropine

I think they overdid the dilating portion of my eye exam:

My Summer of Spectacular Slackerdom

After graduating from residency, I forced myself to put off finding gainful employment...because I'm a workaholic!  From the east coast!  With OCD!  
The early part of my laconic summer was spent designing and hand-sewing outfits for an asian baby doll that belongs to the 4-year-old daughter of a friend.  It was like a Lilliputian version of Project Runway, but without the backstabbing and smarmy comments ("That is so bridesmaid!"; "It looks like a disco straitjacket!"; "I question your taste level!").  My favorite piece is a set of miniature fairy wings I fashioned from an old underwire bra and some glitter.  I think Tim Gunn would approve:

My pack rat tendencies really came in handy for other intriguing outfits made from scraps of denim, stretch cotton, wool, and red velvet:

  

Sadly, my summer of spectacular slackerdom is coming to an end, and soon I'll be shipped off to a locum tenens position in Fairbanks, Alaska where the aurora borealis can be seen 200 nights of each year.

George Washington for Breakfast

3-year-old boy brought to the ED by his family after allegedly swallowing a foreign object earlier in the morning while learning a card trick at the breakfast table.  No airway difficulties.  He looks peachy, but the radiographic evidence tells a different story...

PA CXR: full frontal view of a round, radio-opaque object roughly the size of a quarter
Lateral CXR: the thin, round edge of the foreign object is seen lodged in esophagus

After a heroic extraction by EGD, a slime-covered quarter is retrieved and placed in a specimen cup.

Astute 7-year-old sister: Can we have the quarter back?
Father: [examining the loot] All this fuss over a Connecticut quarter??

Plastic Jesus, Plastic Surgeon

S: Adorable 2-year-old girl frantically rushed by her mother to the pediatric ER after falling from the top bunk bed while clutching a ceramic statue of the Virgin Mary. The statue shattered, slicing open the girl's right temple.

O: T 98.4 . . BP 85/50. . HR 115. . RR 24. . O2 sat 99%
5 cm laceration on R temple approximately 1cm in depth with no discernible ceramic fragments embedded. Subcutaneous tissue and temporalis fascia exposed. Bleeding well controlled [that is to say, until I started stitching...]

A/P:
1. Patient placed under conscious sedation with ketamine.
2. Laceration vigorously irrigated with 0.9% saline solution, sterilized with betadine, anesthetized using 1% lidocaine with epinephrine. Subcutaneous closure with 5-0 vicryl. Skin closure with 8 interrupted stitches of 6-0 nylon.
[Have you ever experienced the delight of using super super thin nylon suture the same color as your squirming pediatric patient's hair??? Exhale a little too enthusiastically and the suture blows all the way across the room. But the results were gorgeous. I could have been a plastic surgeon]
3. Mother advised to keep the wound clean & dry, have stitches removed in 7 days, and strongly urged to use plastic religious icons instead of ceramic.

Let's Order a Round of Pulmonary Emboli

Insanely busy day on call with rapid-fire admissions:

Admission #1: An affable 80-year-old man from a nearby island, s/p hip replacement surgery, on coumadin with a subtherapeutic INR and a right pulmonary embolus. We increase his coumadin, start him on lovenox and run off to...

Admission #2: A 53-year-old attorney recently recovered from a sprained ankle, admitted for chest pain and shortness of breath, found to have small bilateral pulmonary emboli. Really! Lovenox, anyone? Let's throw in some coumadin and a little oxygen by nasal cannula before we head toward...

Admission #3: A 27-year-old G1P0 who is 7 weeks pregnant with a cough and some swelling in her left calf. Are you kidding me?? She, too, has small bilateral pulmonary emboli in addition to a DVT in the left popliteal vein. More lovenox! (but coumadin is verboten, being a teratogen and all...)

I could horrify you with more sordid tales of admissions for pulmonary emboli, but let's quit while we're ahead, shall we?

All About Eve

You do not truly understand the addictive properties of heroin until you take care of a patient who continues to shoot up despite being hospitalized repeatedly for Strep viridans endocarditis, Enterococcus osteomyelitis, methicillin-resistant Staph aureus abscesses, HIV nephropathy, and a dash of Hepatitis C.

The social workers avoid him like the plague because of his outer coating of surliness. He rolls his eyes whenever you enter the room. He refers to his brilliant infectious disease specialist as "that Oriental dude".

But one day you catch him watching "All About Eve" on cable and he admits that he love love loves Bette Davis. A week later he describes an episode of "20/20" about Broken Heart Syndrome and wonders aloud if he has it after all the grief he's experienced in the last 2 years.

Soon you feel like an old married couple when you find him back in his room after an interventional radiology procedure, still wearing the bouffant scrub cap that resembles a glorified shower cap, eating half a watermelon with a spoon. "Look at my pee," he says, pointing to his plastic urine container. "Does that look normal?"

The next time he's admitted to the hospital, you breathe a huge sigh of relief when it's just run-of-the-mill community-acquired pneumonia.